Ha n s - Ge o rg Die t z, Pe t e r P Sch m it t e n b e ch e r

Th e d d y Slo n go , Ka ye E Wilk in s

AO Ma n u al o f Fractu re Man age m e n t

Ela stic Stab le In tram e du llary

Nailin g (ESIN) in Ch ild re n

AO Te a ch in g Vid e o s o n DVD in clu d e d

AO Manual of Fracture Manage m e nt

Hans-Ge org Die tz, Pe te r P Schm itte nbe che r, The dd y Slongo, Kaye E Wilkins

Elastic Stable Intram e dullary Nailing (ESIN) in Childre n

AO Manual of Fracture Manage m e nt

Hans-Ge org Die tz, Pe te r P Schm itte nbe che r, The dd y Slongo, Kaye E Wilkins

Elastic Stable Intram e dullary Nailing (ESIN) in Childre n

29 4 illustrations, 496 picture s and x-rays

30 ste p -by-ste p case de scrip tions
 De sign a n d la yo u t: Sa n d ro Isle r, n o u ga t Gm b H, CH-4 0 5 6 Ba se l Lib ra ry o f Co n gre ss Cata lo gin g-in -Pu b lica tio n Da ta is a va ila b le
Illu stra tio n s: ta d p o le Gm b H, CH-8 0 4 8 Zü rich fro m th e p u b lish e r.

Ha za rd s
Gre a t ca re h a s b e e n ta ke n to m a in ta in th e a ccu ra cy o f th e in fo rm a tio n co n ta in e d in th is p u b lica tio n . Ho w e ve r, th e p u b lish e r, a n d / o r th e d istrib u to r, a n d / or the e d ito rs, an d / o r th e
a u th o rs ca n n o t b e h e ld re sp o n sib le fo r e rro rs o r a n y co n se q u e n ce s a risin g fro m th e u se o f th e in fo rm a tio n co n ta in e d in th is p u blicatio n . Co n trib u tio n s p u b lish e d u n d e r th e n a m e
o f in d ividu a l a u th o rs a re sta te m e n ts an d o p in io n s so le ly o f sa id a u tho rs a n d no t o f th e p ub lishe r, a n d / o r th e d istrib u to r, a n d / o r th e AO Gro u p.
Th e p ro d u cts, p ro ce d u re s, a n d th e ra p ie s d e scrib e d in th is wo rk a re h a za rd o u s a n d a re th e re fo re o n ly to b e a p p lie d b y ce rtifie d a n d train e d m e d ica l p ro fe ssio n a ls in e n viro n m e n ts
sp e cia lly d e sign e d fo r su ch p ro ce d u re s. No su gge ste d te st o r p ro ce d u re sh o u ld b e carrie d o u t u n le ss, in th e u se r‘s p ro fe ssio n al ju d gm e n t, its risk is ju stifie d . Wh o e ve r a p p lie s
p ro d u cts, p ro ce d u re s, a n d th e ra p ie s sho wn o r de scrib e d in th is wo rk will d o th is at th e ir o wn risk. Be ca u se o f ra p id a d va n ce s in the m e d ica l scie n ce s, AO re co m m e n d s th at
in d e p e n de n t ve rifica tio n o f d ia gn o sis, th e ra p ie s, d ru gs, d o sa ge s, a n d o p e ra tio n m e th o d s sh o u ld b e m a d e b e fo re a n y a ctio n is ta ke n .
Alth o u gh a ll a d ve rtisin g m ate ria l wh ich m a y b e in se rte d in to th e wo rk is e xp e cte d to co n fo rm to e th ica l (m e d ical) stan d a rd s, in clu sio n in th is p u b lica tio n d o e s n o t co n stitu te a
gu a ra n te e o r e n d o rse m e n t b y th e p u b lish e r re gard in g q u a lity o r va lu e o f su ch p ro d u ct o r o f th e cla im s m a d e o f it b y its m a n u fa ctu re r.

Le gal re strictio n s
Th is wo rk wa s p ro d u ce d b y AO Pu b lish in g, Da vo s, Switze rlan d . All righ ts re se rve d b y AO Pu b lish in g. Th is p u b lica tio n , in clu d in g a ll p arts th e re o f, is le ga lly p ro te cte d b y co p yrigh t.
An y u se , e xp lo ita tio n o r co m m e rcia liza tion o u tside th e n a rro w lim its se t fo rth b y co p yrigh t le gisla tio n a n d th e re strictio n s o n u se la id o u t b e low , with o u t th e p u b lish e r‘s co n se n t, is
ille ga l a n d lia b le to p rose cu tio n . Th is a p p lie s in p a rticu la r to p h o to sta t re p ro d uction , co p yin g, sca n nin g o r d u p licatio n o f a ny kin d , tra n sla tio n , p re p a ra tio n o f m icro film s, e le ctro n ic
d a ta p ro ce ssin g, a n d sto ra ge su ch as m a king th is p u blica tio n ava ila b le o n In tra n e t o r In te rn e t.
So m e o f th e p ro d u cts, n a m e s, in stru m e n ts, tre a tm e n ts, lo go s, d e sign s, e tc. re fe rre d to in th is p u b lica tio n a re a lso p ro te cte d b y p ate n ts a nd tra d e m a rks o r b y o th e r in te lle ctu a l
p ro p e rty p ro te ctio n la ws (e g, ”AO”, ”ASIF”, ”AO/ ASIF”, ”TRIANGLE/ GLOBE Lo go ” are re giste re d tra d e m a rks) e ve n th o u gh sp e cific re fe re n ce to th is fa ct is n o t a lways m a d e in th e
te xt. Th e re fo re , th e a p p e a ra n ce o f a n a m e , in stru m e n t, e tc. with o u t d e sign a tio n a s p ro p rie ta ry is n o t to b e co n stru e d a s a re p re se n ta tio n b y th e p u b lish e r th a t it is in th e p u b lic
d o m ain .
Re strictio n s o n u se : Th e righ tfu l o wn e r o f an a u tho rize d co p y o f th is wo rk m a y u se it fo r e d u ca tion a l an d re se a rch p u rp o se s o n ly. Sin gle im age s o r illu stra tio n s m a y b e co p ie d fo r
re se arch o r e d u ca tio n a l p u rp o se s o n ly. Th e im a ge s o r illu stratio n s m a y n o t b e a lte re d in a n y wa y a n d n e e d to ca rry th e fo llo win g sta te m e n t o f o rigin ”Co p yrigh t b y AO Pu b lish in g,
Switze rla n d ”.

Co p yrigh t © 2 0 0 6 b y AO Pu b lish in g, Switze rla n d , Cla va d e le rstra sse 8 , CH-7270 Da vo s Pla tz

Distrib u tio n b y Ge o rg Th ie m e Ve rla g, Rü d ige rstra sse 14 , DE-70 4 6 9 Stu ttga rt a n d
Th ie m e Ne w Yo rk, 333 Se ve n th Ave n u e , Ne w Yo rk, NY 10 0 01, USA

ISBN-10 : 3 -13 -143331-0 (GTV)

ISBN-13 : 978 -3 -13 -143331-2 (GTV)
ISBN-10 : 1-5 8 8 9 0 -4 8 5 -7 (TNY)
ISBN-13 : 978 -1-5 8 8 9 0 -4 8 5 -0 (TNY)

iv
Contributors

Ed it o rs Au t h o rs

Han s-Georg Dietz, M D Peter Illin g, M D

Professor of Ped iatric Su rgery Ch ildren s Hospital “Park Sch ön feld”
Lu dw ig-Maxim ilian s-Un iversity Departm en t of Ped iatric Su rgery
Mu n ich Fran k fu rter Strasse 167
Dr. von Hau n ers Ch ildren s Hospital DE-34121 Kassel
Departm en t of Pediatric Su rgery
Lin dw u rm strasse 4 Prof Pierre Lascom bes, M D
DE-80337 Mü n ch en Hôpital Brabois En fan ts
Ru e du Mor van
Peter P Sch m itten bech er, M D FR-54511 Van doeu vre
Ass. Professor of Ped iatr ic Su rger y
Clin ical Cen ter “Barm h erzige Brü der”
Departm en t of Pediatric Su rgery
Stein m etzstrasse 1–3
DE-93049 Regen sbu rg

Th eddy Slon go, M D

Ped iatric Trau m a an d Orth oped ics
Un iversity Ch ild ren ‘s Hospital
Departm en t of Pediatric Su rgery
CH-3010 Bern

Kaye E Wilkin s, DVM , M D

Professor of Orth oped ics an d Ped iatrics
Departm en t of Orth oped ics
Un iversity of Texas Health Scien ce
Cen ter at San An ton io
7703 Floyd Cu rl Drive
US-7828 4-7774 San An ton io, Texas

v
vi
Fore word

Ka ye E Wilk in s

“Ch ildren ’s fractu res all do well w ith n on operative treatm en t” of m u scle fu n ction an d reestablish m otion m ore read ily. Lon g-
was th e em ph asis in th e past. Th e pion eer in th e treatm en t term rigid stabilization tech n iqu es are rarely n eeded.
of ped iatr ic orth oped ic fractu res, Dr Walter Blou n t, was very
opposed to su rgical in ter ven tion [1]. In h is classic textbook Fin an cial an d so cial p re ssu re s. A classic exam ple in th e
pu blish ed in 1955, h e stated “Operation s on su pracon dylar past was th e m an agem en t of treatin g fractu res of th e fem o-
fractu res are frequ en tly followed by restricted m otion ”. He ral sh aft. Th ese ch ildren were often m an aged as in patien ts in
wen t on to say, “Th e u se of in tern al xation , becau se con - traction for weeks wh ich was both ex pen sive an d debilitatin g.
ser vative m an agem en t fails, is t h e w ay o f an im p e t u o u s In patien t h ospitalization is ver y costly. With both paren ts
su rge o n ”. Th is dogm a establish ed n on operative tech n iqu es as u su ally em ployed, h ospitalization also pu t social pressu res on
th e stan dard for treatin g fractu res in ch ild ren for m an y years. th e fam ily. Psych ologically, ch ildren do better wh en m an aged
Certain ly, in 1955 w h en h is textbook was pu blish ed, th e su r- in th eir h om e en viron m en t. Tech n iqu es were th u s developed
gical m an agem en t of ch ildren ’s fractu res u su ally requ ired th e to stabilize th ese fractu res so th at th e ch ild ren cou ld be d is-
u se of exten sive in vasive tech n iqu es w ith large in cision s. ch arged after m in im al h ospitalization .

As tim e h as passed, th ere h as been a dram atic ch an ge in th e To m eet th e n eed to m obilize th e ch ild ren m ore rapid ly, m in i-
m an agem en t of ch ildren ’s fractu res. Su rgical m an agem en t h as m ally in vasive tech n iqu es were developed an d re n ed. Th e
becom e m ore w idely accepted an d u tilized. Th is h as n ot been rst tech n iqu es u tilized were extern al xators. Wh ile effec-
becau se th e presen t gen eration of su rgeon s m an agin g ch il- tive in m an agin g m an y lon g bon e fractu res, th ey were n ot
dren ’s fractu res h as becom e m ore im p e t u o u s. Th e in crease well accepted by th e patien ts. Th ere were th e m ajor problem s
in th e u se of su rgical tech n iqu es h as becom e accepted becau se of scar form ation an d local in fection at th e pin sites.
of th ree m ajor factors:
1. Im provem en t in tech n ology, In tram edu llary stabilization tech n iqu es becam e popu lar at
2. Ch ildren ’s fractu res h eal rapid ly, th u s lon g-term rigid xa- abou t th e sam e tim e. In adu lts, rigid in tram edu llary xation
tion is u n n ecessary, h as becom e w idely accepted. However, for m any biological
3. Fin an cial an d social pressu res. reason s, th is type of stabilization is n ot appropriate in th e
skeletally im m atu re. Th e early attem pts at in tram edu llar y
Te ch n o lo gy. Newer tech n ology item s su ch as im age in ten si- stabilization u tilizin g Ru sh rods or Stein m an n pin s d id n ot
ers, can nu lated screw s, m ore exible im plan ts, an d power produ ce satisfactory resu lts. By m ak in g th e in tram edu llar y
d rills h ave en abled fractu re xation to be perform ed w ith devices m ore ex ible, th ey becam e ver y u sefu l in th e ped iat-
m in im al tissu e d istu rban ce. Thu s, th e procedu res h ave ric age grou p. Th an ks to th e work of th e pion eers in Fran ce,
becom e m arkedly less in vasive. Previou sly, su rgical treatm en t Sw itzerlan d, an d Germ an y, th e con cept of Elastic Stable In tra-
m ean t large in cision s w ith m ore tissu e dam age. m edu llary Nailin g (ESIN) was developed. Th is tech n iqu e
of u tilizin g exible in tram edu llary n ails h as revolu tion ized
Rap id h e alin g. Sin ce th e fractu re h ealin g processes are m u ch th e m an agem en t of lon g bon e fractu res in th e skeletally
m ore rapid in ch ildren , th e developm en t of th e n atu ral stabi- im m atu re. Th e Eu ropean orth oped ic com m u n ity h as gain ed
lization processes of fractu re h ea lin g elim in ates th e n eed for con siderable ex perien ce in th is tech n iqu e. Two m ajor text-
lon g-term im m obilization . Ch ildren h ave m ore rapid retu rn books h ave been produ ced, on e in Fren ch [2] an d a secon d in

vii
 Germ an [3 ]. Th u s, th e Eu ropean com mu n ity h as h ad th e lu x- [1] Blo u n t WP (1955) Fractures in Children. 2n d ed. Baltim ore:
u ry of h avin g access to referen ce works on th e basic prin ciples William s & Wilkin s.
plu s th e ex perien ce of th e w ide u se of ESIN. Un fortu n ately, [2] Me t aize au J P (1988) Ostéosynthèse de l’enfant par embro-
th e En glish speak in g orth oped ic su rgeon s h ave been h an d i- chage centro-médullaire élastique stable. Mon tepellier:
capped by n ot h avin g a referen ce sou rce in En glish . Th ey h ave Sau ram ps Méd ical.
h ad to depen d on jou rn al articles an d som e sh ort cou rses for [3 ] D ie t z HG (1997) Intramedulläre Osteosynthese im Wachstums-
th eir gu idan ce on th e u se of ESIN. alter. Mü n ch en Wien Baltim ore: Urban & Sch warzen berg.

Th is m an u al w ill go far to correct th at de cien cy. Becom -

in g accom plish ed in u tilizin g th e tech n iqu es of ESIN in th e
En glish speak in g orth oped ic com m u n ity h as in th e past car-
ried w ith it a sign i can t learn in g cu r ve. Th e com pleten ess of
th is pu blication in pu ttin g togeth er th e basic prin ciples, th e
description of th e u se of th e specialized in stru m en ts an d th e
step-by-step description of th e speci c tech n iqu es for each
fractu re type w ill greatly decrease th is learn in g cu r ve. I pre-
d ict th at th is work w ill becom e an excellen t resou rce for th ose
En glish speak in g su rgeon s treatin g fractu res in th eir skele-
tally im m atu re patien ts.

Th e prim ar y au th ors of each of th e ch apters h ave sh ared w ith

th e reader th eir w ide ex perien ce w ith th e ESIN tech n iqu es in
a clear an d con cise m an n er. As is con sisten t w ith AO Pu blish -
in g, th is m an u al is well organ ized an d easy to follow. I am
h on ored to h ave been asked to provide editorial direction an d
advice in th e produ ction of th is valu able resou rce.

Fin ally, it mu st be rem em bered th at th e m ajor ity of fractu res

in ch ild ren can still be treated by n on operative m eth ods.
However, for th ose fractu res th at w ill h ave a better ou tcom e
wh en stabilized su rgically, th is m an u al w ill provide gu idan ce
as to th e m ost appropriate m eth ods of u tilizin g th e ESIN tech -
n iqu e.

Kaye E Wilkin s, M D
San An ton io, Texas

viii
Introduction

Ha n s - Ge o rg Die t z, Pe t e r P Sch m it t e n b e ch e r, Th e d d y Slo n go , Ka ye E Wilk in s

Th is m an u al is ded icated to operative fractu re treatm en t in in clu d in g all su rgical con sideration s, postoperative care an d
ch ildren an d w ill in trodu ce th e reader to a special tech n iqu e resu lts, fu rth erm ore, th e pitfalls an d pearls w ill be set ou t for
called Elastic Stable In tram edu llary Nailin g (ESIN), wh ich addition al clarity. Th e practical u se of ESIN w ill be illu strated
is today th e treatm en t of ch oice for th e m ajority of sh aft w ith referen ce to a large nu m ber of typical fractu res w ith
fractu res in th e grow in g ch ild, especially in th ose situ ation s m u ltiple case presen tation s for ever y segm en t of th e u pper
wh ere con servative treatm en t wou ld n ot be in d icated. an d lower extrem ities. Fin ally, exten ded in d ication s for ESIN
in term s of special or rare cases an d path ological fractu res
Most of th e tech n iqu es gen erally applied in adu lts like w ill also be in clu ded.
in terlock in g n ailin g or platin g are n ot ideally su ited to th e
treatm en t of ch ildren du e, for exam ple, to th e risk of ph ysis In th e rst part we give a com plete overview of th e ESIN
in ju r y, an d overgrow th . tech n iqu e as applied to th e u pper an d lower extrem ities. In
th e secon d part we sh ow exten ded in d ication s for ESIN in
Th e au th ors h ave becom e fam iliar w ith th is m eth od over a rare cases an d path ological fractu res.
per iod of twen ty years an d it is a great pleasu re to presen t
th e ph ilosoph y of th e m eth od, ou tlin e th e tech n iqu e, Th is m anu al is in ten ded for all ped iatric, trau m a, an d
an d offer advice on h ow to m an age special situ ation s an d orth oped ic su rgeon s dealin g w ith th e operative treatm en t of
com plication s. ch ild ren s fractu res. Th e book provides a lot of “h an ds on ” an d
“h ow to u se” in form ation . It is to be regarded as a “m an u al”
ESIN is recom m en ded prim arily for sh aft fractu res an d all in th e tru e sen se of th e word: you take it, n d you r case or a
th e possible in d ication s an d tech n iqu es w ill be presen ted. sim ilar on e, an d in form you rself abou t th e steps of th e operative
However, som e special in d ication s for m etaphyseal an d join t procedu re as th ey are recom m en ded by an in tern ation al
fractu res also exist an d th ese w ill be explain ed in detail, too. grou p of ex perien ced u sers wh o are able to d raw n ot on ly on
Th e m an u al starts by statin g th e biom ech an ical prin ciples th eir ow n ex perien ce, bu t also on th e ex perien ce of oth ers
of fractu re treatm en t on w h ich ESIN tech n iqu e is based. an d advan ced train in g gain ed by participation at n u m erou s
It goes on to explain th e developm en t of th e m eth od, th e n ation al an d in tern ation al worksh ops an d cou rses.
requ ired equ ipm en t, th e in dication s, plan n in g th e procedu re

ix
x
Acknowle dge m e nts

Th e idea for a n ew book an d th e desire to w rite it often arise

qu ite spon tan eou sly. In con trast, its realization in term s of
processin g an d produ ction requ ires a great deal of plan n in g,
h ard work, an d m u tu al u n derstan din g.

Th erefore, it is of great im portan ce to th e ed itors th at th ey

exten d th eir th an ks to all th ose wh o h ave h elped to ach ieve
th is “stan dard work“ on ESIN treatm en t of fractu res in
ch ild h ood.

In th e rst in stan ce, ou r th an ks go to th e AO Organ ization ,

especially AO Pu blish in g, wh o offered u s th e opportu n ity to
w rite th is book in th e rst place.

For th eir active su pport an d gu idan ce, we wou ld particu larly

like to th an k M iriam Uh lm an n , Project Coord in ator for h er
u n tirin g com m itm en t to th e project, Han n a Ju fer, illu strator,
for h er m asterly, ch ild-speci c d raw in gs, an d Urs Rü etsch i,
Head of AO Pu blish in g.

We also w ish to th an k ou r two gu est au th ors, Peter Illin g an d

Pierre Lascom bes, for th eir collaboration .

A book is on ly easy an d pleasan t to read if th e ph raseology is

as perfect as possible an d th e text is correctly w ritten an d so a
special an d h eartfelt th an kyou goes to Kaye Wilk in s an d h is
w ife for th eir dedicated an d profession al revision an d ed itin g
of ou r texts. It is a particu lar h on or for u s to be able to in clu de
th e n am e of Kaye Wilk in s in ou r list of ed itors.

Han s-Georg Dietz, Peter Sch m itten bech er, Th eddy Slon go

xi
 To access additional material available for this e-book, please go to MediaCenter.thieme.com.
You will be asked to login to this site using your thieme.com account credentials. If you don’t
have a thieme.com account, please register first. Click on “All titles” at the top of the page to find
the additional material for your e-book and enter the following access code to gain access:
Z6N7-LV5Y-2G9E-VKP9

xii
Table of conte nts

1 Basic principles 1

2 Case collection of hum eral fractures 21

3 Case colle ction of e lbow fractures 45

4 Case collection of forearm fractures 71

5 Case colle ction of fem oral fracture s 109

6 Case collection of tibial fractures 149

7 Case colle ction of special indication fracture s 171

Appe ndix 225

xiii
 1 Basic principle s

1.1 Bio m e ch a n ics 1

1 Ba sics o f e la s tic s ta b le in tra m e d u lla ry n a ilin g
(ESIN) in ch ild re n 1
2 Bio m e ch a n ica l p rin cip le s 2
3 Bio m e ch a n ica l p ro p e rtie s 4
4 Sp e cia l te ch n iq u e s d e sign e d to im p ro ve th e
b io m e ch a n ics 7
5 Ad a p ta tio n o f th e b io m e ch a n ica l p rin cip le s to
d iffe re n t a p p ro a ch e s 9
6 Su gge ste d re a d in g 14

1.2 Im p la n t s a n d in s t ru m e n t s 15
1 Im p la n t d e sign s a n d p ro p e rtie s 15
2 In s tru m e n ts 16

xiv
1.1 Biom e chanics

1 Ba s ics o f e la s t ic s t a b le in t ra m e d u lla r y n a ilin g

(ESIN) in ch ild re n

1.1 Wh a t is ESIN? 1.2 Bio lo g y

St a b ilit y p lu s m o b ilit y Wh y is th is tech n iqu e biological an d ch ild frien d ly?

Elastic stable in tram edu llary n ailin g (ESIN) is a m in im ally
in vasive an d m in im ally trau m atic su rgical tech n iqu e design ed Ra p id h e a lin g
to treat fractu res in ch ildren . Stabilization is ach ieved w ith Th e su ccess of th e ESIN tech n iqu e is largely du e to th e fact th at
exible in tram edu llary n ails th at h ave been precon tou red to it produ ces less adverse effects on th e h ealin g of th e fractu re
provide som e elastic properties ( Fig 1.1-1). Th is en ables th em to an d th e grow th processes th an oth er m ore invasive m eth ods.
provide su f cien t stability to perm it early m ovem en t an d par- Becau se of th e elastic properties of th e n ails, th is system su p-
tial weigh t bearin g. Th u s, ESIN is a biological an d ch ild- ports th e biology of ch ildren ’s fractu re h ealin g by stimu latin g
frien dly m eth od of osteosyn th esis for tran sverse, obliqu e, an d both periosteal an d en dosteal callu s form ation ( Fig 1.1-2 ).
sh ort spiral d iaphyseal fractu res in th e im m atu re skeleton .
Sin ce th is is a m in im a lly in vasive tech n iqu e, th e periosteu m
Me t a p h ys e a l u s a ge is respected an d preser ved. Cu ttin g or strippin g th e perios-
Th e m eth od is also su itable for th e treatm en t of som e special teu m , w h ich u su ally occu rs w ith an y open procedu re, h as a
m etaph yseal fractu res su ch as: deleteriou s effect on h ealin g—it slow s dow n both th e speed of
Rad ial n eck fractu res h ealin g an d callu s form ation . Th is slow in g of th e reparative
Prox im al an d d istal m etaph yseal-epiph yseal fractu res of processes, can in tu rn affect th e len gth of th e extrem ity by
th e h u m eru s delayin g th e stim u lation of grow th associated w ith th e h eal-
Prox im al an d d istal m etaph yseal fractu res of th e fem u r in g process.

Fig 1.1-1 Th is m odel dem on strates th e ideal position in g an d

cu r vatu re of th e n ails in th e treatm en t of a m idsh aft fractu re
of th e femu r.
Fig 1.1-2 Histological view of periosteal an d
en dosteal callu s form ation after ESIN. (Repro-
du ced w ith k in d perm ission of Métaizeau J P,
Ostéosyn th èse ch ez l’en fan t; Sau ram ps Med i-
cal 1988.)
1
 1 Ba s ic p rin cip le s

solidation an d rem odelin g tim e. Th is in tu rn decreases th e

tem poral aspect of th e h ealin g process. Th is ex plain s wh y less
overgrow th h as been obser ved in th ose patien ts treated w ith
th e ESIN tech n iqu es. Elastic n ailin g redu ces an d adequ ately
stabilizes d iaph yseal an d m etaph yseal fractu res in term s of
len gth , rotation , an d align m en t.

Th e redu ction m u st be “an atom ical” in as m u ch as it corre-

spon ds to th e respective rem odelin g capacity based u pon th e
age of th e ch ild an d th e localization of th e fractu re.

To ach ieve a su ccessfu l ou tcom e, it is im perative th at th e treat-

in g su rgeon acqu ires th e basic k n owledge to correctly apply
th is m eth od.

a b
2 Bio m e ch a n ica l p rin cip le s

Fig 1.1-3 a – bAP an d lateral x-rays at 4 m on th s postoperative

dem on stratin g alm ost com plete rem odelin g of th e callu s. 2 .1 Ba s ic p ro p e r t ie s

Th e elastic n ails u sed to stabilize ch ildren ’s lon g-bon e frac-

tu res, wh eth er of titan iu m alloy or of stain less steel, h ave
Pre s e r ve d p e rio s t e u m adequ ate stren gth to m ain tain th e redu ction u n til th e frac-
Sin ce th e fractu re is u su ally m an aged in closed tech n iqu e, tu re h as h ealed. It sh ou ld be n oted th at ESIN is a su ccessfu l
ESIN produ ces a m ore n orm al biological en viron m en t by m eth od for treatin g ch ildren ’s fractu res becau se th ey h eal
m in im izin g th e periosteal dam age. Even wh en an open redu c- rapid ly in less th an h alf th e tim e of an equ ivalen t adu lt frac-
tion is requ ired, th e su rgical in cision over th e fractu re zon e is tu re.
m in im al, bein g n o m ore th an is n ecessar y to facilitate th e
redu ction . 2 .2 Pre co n t o u r

Micro m o t io n It is recom m en ded th at th e n a ils are precon tou red in order to

Th e elasticity of th e two properly ben t n ails perm its an ideal ach ieve 3-poin t con tact. Th e degree of cu r vatu re of th e n ail
m icrom otion wh ich en h an ces th e rapidity of fractu re h ealin g sh ou ld be approx im ately 3 tim es th e d ia m eter of th e bon e at
( Fig 1.1-3 ). th e fractu re site ( Fig 1.1-4 ). Add in g m ore of a cu r ve w ith pre-
con tou r in g can in crease th e con tact force on th e in n er cor-
Th e decrease in th e h ealin g tim e com bin ed w ith th e adequ acy tex. Th is ca n be a de n ite adva n tage in th e stabilization of
an d stability of th e fractu re redu ction h elps to redu ce th e con - u n stable fractu res.

2
 1.1 Bio m e ch a n ics

3× d

a b

Fig 1.1-4 Precon tou rin g th e n ails to 3 tim es th e d iam eter of Fig 1.1-5 a – bGood an ch orage of both th e tips of th e n ails in
th e d iaph ysis w ith m ax im al cu r vatu re at th e level of th e frac- th e m etaph yses is essen tial to en h an ce stability.
tu re.

Som e au th ors do n ot precon tou r th e n ails before in sertion , su itable for ch ild ren ’s fractu res is th e den sity of th e bon e in
allow in g th e n ails to becom e self-con tou red du r in g th e pro- th eir m etaph yses. Becau se of th e stability provided by th e
cess of in sertion . However, ex perim en tal stu d ies h ave dem on - n ails in th eir respective m etaphyses, th ey resist th e ten den cy
strated th at a lon ger con tact area of th e n ails w ith th e in n er to be straigh ten ed. Th is, in tu rn , in creases th e ten sion w ith in
cortex as well as a h igh er “sprin g effect” can in crease th e ax ial th e in tram edu llar y can al an d, likew ise, resists th e ten den cy
stability by a factor of 15 (see Tab 1.1-1). Th e apex of th e cu r va- for fu rth er deform ation .
tu re sh ou ld be at th e level of th e fractu re. Thu s, wh en fractu res
are n ot in th e m idsh aft, it m ay be easier to place th e apex at 2 .4 Ro le o f s o ft t is s u e s
th e appropriate location by precon tou rin g th e n ail.
Part of the biomech an ical stability of fractu res stabilized by
2 .3 St a b ilit y fa ct o rs ESIN is provided by th e intact mu scle and other soft-tissue enve-
lopes su rrou ndin g the affected bone. Thu s, ESIN is particu larly
In th e vast m ajority of cases two n ails of th e sam e d iam eter effective for closed fractu res of the femu r and forearm .
are u sed. Th ese n eed to be iden tically precon tou red an d
in serted opposite each oth er in order to produ ce a perfectly Mu ltifragm en tar y fractu res an d fractu res associated w ith
balan ced con stru ct to m ain tain align m en t. It is also im pera- exten sive soft-tissu e loss or strippin g, su ch as Gu stilo type III
tive th at th ere is good an ch orage of both th e tips an d th e en ds open tibial fractu res, m ay be m ore d if cu lt to stabilize w ith
of th e n ails in th eir respective proxim al an d d istal m etaph yses ESIN alon e. In th ese situ ation s, ESIN m ay n eed to be su pple-
( Fig 1.1-5 ). An oth er featu re th at m akes th is m eth od prim arily m en ted by a tem porar y extern al xator or a splin t.

3
 1 Ba s ic p rin cip le s

2 .5 Sp e cia l co n d it io n s 3 .1 St a b ilit y fa ct o rs

Occasion ally, th ree n ails are in trodu ced in to a sin gle lon g Axia l s t a b ilit y
bon e. It sh ou ld be n oted th at th is can u pset th e balan ce of th e Th e rebou n d forces of th e n ails ten d to brin g th e fragm en ts back
bipolar m atch ed con stru ct. Th erefore, it sh ou ld be u sed on ly to the origin al position . To ach ieve th is axial stability optim ally,
to resist an excessive extern al deform in g force su ch as a spas- it is necessary th at the n ails h ave a lon g con tact area w ith the
tic m u scle. Th ere are con d ition s wh ere it is advisable to u se in n er cortex. Th e n ails mu st form a kin d of “parallelogram”
th ree n ails, for exam ple, in th e prox im al fem u r (see Fig 7.3 -7, alon g the fractu re zon e. When axial strain is applied, the in ner
Fig 7.3 -8 , Fig 7.3 -9 in ch apter 7.3 Path ological fem oral frac- pressu re on th e cortex w ill in crease ( Fig 1.1-6 ).
tu res). Th ese are special situ ation s wh ere th e basic biom e-
ch an ical prin ciples do n ot apply. Tra n s la t io n a l s t a b ilit y
Th e parallel position of th e n ails also ser ves to resist tran sla-
tion al d isplacem en t.
3 Bio m e ch a n ica l p ro p e r t ie s
Th e lon ger th e con tact area of th e n ails at th e in n er cortex,
th e greater is th e resistan ce to tran slation al d isplacem en t
Th e biom ech an ical prin ciple of ESIN is based on th e sym m et- ( Fig 1.1-7, Tab 1.1-1). In tu rn , th is en h an ces th e optim al con -
rical bracin g of two elastic n ails in serted in to th e m etaph ysis, stru ction of th e parallelogram .
each su pportin g th e in n er cortical con tact. Th is produ ces th e
follow in g fou r biom ech an ical properties:
Ben d in g/ bow in g stability
Ax ial stability
Tran slation al stability
Rotation al stability
All are essen tial to ach ievin g an optim al resu lt.

Th e ab o ve pro p e rtie s o n ly co nd itio na lly apply to th e

tre a tm e n t o f m e ta p h yse a l fra ctu re s. On ly b y ad h e rin g to
th e b a sic prin ciple s ca n su f cie n t su pp o rt o r stabilit y b e
ach ie ve d in th e m e ta ph yse a l a re a s. Th e su rge o n sh o u ld ,
ho we ve r, ap p ly th e se b a sic prin ciple s a s m u ch a s th e
in d ivid u a l fra ctu re p a tte rn w ill allo w.

Th e follow in g two basic con cepts m u st always be kept in

m in d:

1. Ten sion w ith in th e n ail provides a “m em or y effect”.

a b
2. Th e elastic n ails provide stability again st extern al forces.
Fig 1.1-6 a – b Lon g in n er-cortical con tact con tr ibu tes to sta-
bility in th e ax ial plan e.

4
 1.1 Bio m e ch a n ics

Ro t a t io n a l s t a b ilit y Most failu res occu r for th e follow in g reason s:

Th e elastic n ails also ach ieve stability again st rotation al exter- Wron g in d ication as to th e type or localization of th e frac-
n al forces ( Fig 1.1-8 ). Even in u n stable fractu res, th e n ails m u st tu re or age an d weigh t of th e ch ild
be well secu red in th e prox im al an d d istal m etaph yses. In correct size of th e n ails: ch oosin g th e w ron g diam eter
(ie, too th in) or u sin g n ails of differen t d iam eters
3 .2 Fa ct o rs le a d in g t o fa ilu re Wron g tech n iqu e: ch oosin g differen t levels for th e en tr y
poin ts or produ cin g th e so-called corkscrew ph en om en on
Fa ilu re s o f t h e s u rge o n Failu re by om ission : n ot respectin g th e biom ech an ical
In gen eral, it looks ver y sim ple to h am m er two elastic n ails prin ciples of ESIN
in to a bon e. Becau se of th e fact th at fractu res alm ost always
h eal in th e ch ild, th e su rgeon m ay h ave a ten den cy to om it Th ese speci c m istakes are dem on strated an d d iscu ssed in
som e of th e im portan t aspects of th e treatm en t n ecessar y for detail in Fig 1.1-9 .
su ccess. Often th e failu re an alysis of th is m eth od dem on -
strates th e absen ce of ad h eren ce to th e basic biom ech an ical
prin ciples. Un fortu n ately, in situ ation s wh ere th is occu rs it
is u su ally th e su rgeon ’s m istake an d n ot th e fau lt of th e
m eth od.

R
F

F F

a b c d a b

Fig 1.1-7a – dTran slation al stability. Th e parallel position of th e n ails pro- Fig 1.1-8 a – bRotation al stability.
vides resistan ce to tran slocation as well, even in m u ltifragm en tary frac- Rotation al rebou n d forces brin g th e frag-
tu res. m en ts back in to th e correct position .

5
 1 Ba s ic p rin cip le s

Fa ilu re t o e va lu a t e p a t t e rn s Ch oosin g n ails of in adequ ate th ick n ess: Th is can also con -
In dividu al failu res m ay also occu r if th e pattern of th e fractu re tribu te to a loss of th e fractu re stability produ cin g m alalign -
is n ot taken in to con sideration . Speci c exam ples in clude: m en t ( Fig 1.1-10 ) (too th in n ails = loss of stability; too th ick
Differen t levels of th e en try poin ts: Th is often produ ces n ails = loss of elasticity).
d ifferen t con tact w ith th e in n er cortex lead in g to d ifferen t Use of on ly on e n ail: Th is is n ot in keepin g w ith th e basic
stren gth of th e n ails wh ich can resu lt in ax ial deviation . biom ech an ical prin ciples an d th u s can n ot be con sidered a
stable system .

a b a b

Fig 1.1-9 a – b Th is case dem on strates a com bin ation of d iffer- Fig 1.1-10 a – bLoss of align m en t. Becau se of failu re to ch oose
en t failu res in th e sam e patien t. Th ere is a failu re of tech n iqu e n ails of adequ ate d iam eters, th ere is a loss of stability. Th is
as m an ifested by a lack of cortical con tact becau se of failu re to resu lts in su bstan tial deform ation of th e n ails w ith weigh t
precon tou r th e n ail (1). Th e n ail d iam eters are too sm all ( 2 ). bearin g.
In add ition th ere is a corkscrew ph en om en on ( 3 ).

6
 1.1 Bio m e ch a n ics

4 Sp e cia l t e ch n iq u e s d e s ign e d t o im p ro ve t h e Lo cking de vice Axia l Be nding To rs io n

b io m e ch a n ics co m pre s s io n (Nm/ de g ) 45º
(N)
No lo ckin g 10 N 0 .18 Nm / d e g 0 Nm
4 .1 Ma in t a in in g t h e a d va n t a ge s o f ESIN

2–2 .5 m m K-w ire s 35 0 N 0 .2 2 Nm / d e g

ESIN perm its adequ ate stabilization of alm ost all diaphyseal
fractu res in patien ts aged 4 –14 years. Neverth eless, certain
well-k n ow n problem s in th e treatm en t of ver y lon g spiral 2–2 .5 m m th re ade d 35 0 N 0 .18 Nm / d e g
fractu res an d mu ltifragm en tary fractu res rem ain . By takin g K-w ire s
all biom ech an ical pr in ciples in to accou n t an d adh er in g to th e 2–3 .5 m m scre w s 65 0 N 0 .26 Nm / de g 0 .3 8 Nm
correct tech n iqu e, th ese problem s can largely be avoided.

4 .2 Ca u s e s o f in s t a b ilit y
Ta b 1.1-1 Effects of in creasin g n ail spread at crossin g poin ts.
In su f cien t stability m ay occu r in th e follow in g circu m -
stan ces:
Older an d tall ch ildren
Ph ysically d isabled ch ildren w ith spastic or paralytic
d isorders
Com plex fractu res in sm aller ch ild ren
Th e fractu re zon e to be addressed is situ ated in th e
proxim al or d istal th ird
Lack of an ch orage in osteoporotic bon es

4 .3 Ad a p t a t io n s t o in cre a s e t h e in t e rn a l p re s s u re

Th e qu estion arises as to wh eth er it is possible to im prove th e

biom ech an ics of ESIN. Yet u n pu blish ed research carried ou t at
th e AO Research In stitu te in Davos, Sw itzerlan d, h as sh ow n
th at add ition al spread in g at th e in tersection poin t of th e n ails
can in crease th e in n er pressu re so m u ch th at th e axial stabil-
ity in creases by a factor of 65 ( Tab 1.1-1, Fig 1.1-11). Th e m odel
u sed was th e so-called “gap m odel” th at sim u lated th e situ a-
tion of a com pletely u n stable fractu re. Fig 1.1-11 Test arran gem en t w ith 3.5 m m screw s.

7
 1 Ba s ic p rin cip le s

b c d a b c

Fig 1.1-12 a – d M iss-a-n ail tech n iqu e. Fractu re of th e proxi- Extern al xation su pplem en tation . A patien t
Fig 1.1-13 a – c
m al th ird of th e tibia stabilized by ESIN. To in crease th e w ith cerebral palsy an d epilepsy su stain ed a lon g u n stable
stability by ch an gin g th e crossin g poin t to a m ore proxim al spiral wedge fractu re of th e fem u r. Th e align m en t was easily
location , a 3.5 m m cortex screw was u sed in m iss-a-n ail tech - accom plish ed w ith two n ails. To preven t sh orten in g a sm all
n iqu e. extern al xator was applied to th e screw s placed in each of th e
apices on th e d iaph yseal side of th e crossin g poin ts (arrow s)
for 3 weeks.

4 .4 In cre a s e in t e rn a l p re s s u re —m is s -a -n a il t e ch n iq u e In sertion of a 3.0 m m or 4.0 m m self-drillin g, self-tappin g

Sch an z screw in to th e apices on th e d iaph yseal side of th e
Add ition al spread in g to in crease th e pressu re on th e in n er crossin g poin ts an d con n ection via a sm all extern al xator
cortex can be ach ieved: rod ( Fig 1.1-13 ).
In sertion of a 3.5 m m cortex screw close to eith er on e or
both of th e proxim al or d istal apices on th e d iaph yseal side The holes for the screws sh ou ld be drilled w ith Stein m an pin s
of th e crossin g poin t ( Fig 1.1-12 ). an d n ot a drill bit to lessen th e ch ance of in ju rin g the exible
n ails.

8
 1.1 Bio m e ch a n ics

Can nu lated screws shou ld be u sed to facilitate later rem oval. 5 .1 Sin gle -s id e n a il in s e r t io n

Th ese are m eth ods of simu latin g rein forced precontou rin g to Th e m ost su bstan tial adaption is requ ired for th ose fractu res
in crease th e pressu re again st the in ner cortices. w h ere it is on ly possible for th e n ails to be in serted in to th e
bon e from on e side (bu t th rou gh d ifferen t in sertion sizes).
Th u s, th e len gth , rotation , an d an gu lation can be optim ally Th is is especially relevan t to fractu res of th e distal an d proxi-
stabilized. Th e advan tages lie in im m ediate, u n problem atic m al hu m eru s an d d istal fem u r.
m obilization an d partial weigh t bearin g. In ph ysically h an d i-
capped patien ts, gen eral care an d position in g in th e wh eel- S-s h a p e co n gu ra t io n
ch air is im m ediately possible.
Wh en both n ails are in serted on on e side on ly, on e of th ese
Sin ce adequ ate callu s form ation can be ex pected w ith in 2–3 n ails m u st be rotated by 180 º du rin g th e in trodu ction process
weeks of biological treatm en t w ith ESIN, th e sm all extern al to produ ce th e S-sh ape ( Fig 1.1-14 ). Th is S-sh ape con gu ration
xator, if applied, can be rem oved at th is tim e. Stability is is n ecessary wh en m an agin g th e hu m eru s in both an tegrade
th en com pletely assu red. an d retrograde in sertion tech n iqu es com bin ed w ith sin gle-side
in sertion ( Fig 1.1-15 , Fig 1.1-16 ).
If screw s were in serted, th ey sh ou ld be extracted rst at th e
tim e of n ail rem oval.

Th e m iss-a-n ail tech n iqu e offers th e option of ex pan d in g th e

Fig 1.1-14 a – b S-sh ape con gu -
in d ication s for th e ESIN m eth od. It n eeds to be m en tion ed
ra tion . Th e rst precou n tered
th at th is tech n iqu e is u sed in a sim ilar way w ith oth er prod-
n ail is n orm ally advan ced in th e
u cts, su ch as special n ails th at h ave an eyelet at th e en d of th e
an tegrade d irection . Th e secon d
n ail. However, th ese n ails can be applied on ly in ver y special
n ail is ch an ged in to an S-sh ape
circu m stan ces. An oth er option to in crease stability is to u se
con gu ration du rin g its in ser-
th e en d cap (see Fig 1.2-2 ).
tion process.

5 Ad a p t a t io n o f t h e b io m e ch a n ica l p rin cip le s t o

d iffe re n t a p p ro a ch e s

To be able to appropr iately treat all d iaph yseal fractu res, th e

su rgeon m u st be able to adapt th e stan dard tech n iqu es. How-
ever, if th e tech n iqu e is am en ded, it is always im portan t to
ad h ere to th e basic biom ech an ical prin ciples. Som e of th e
fractu re pattern s h ave u n iqu e featu res. Th is requ ires learn in g
wh ich speci c adaptation s of th e basic prin ciples are essen tial
for th eir treatm en t.
a b

9
 1 Ba s ic p rin cip le s

5 .2 Wid e s e p a ra t io n o f t ip s Th is is becau se th e apex of th e con tou red portion does n ot lie

w ith in th e fractu re zon e. Placin g th e tips in w idely separated
In th e very d istal fractu res in th e m etaph ysis, it is im portan t, areas of rigid m etaph yseal bon e provides optim al stabilization
th at rigid stabilization of th e tips is obtain ed. In oth er words, for th e fractu re ( Fig 1.1-15 , Fig 1.1-16 ).
th e tips n eed to be secu rely placed in good m etaph yseal bon e.

Fig 1.1-15 Cor rect posit ion of t h e n a ils u sin g th e retrograde Fig 1.1-16 Correct position of th e n ails an d ben d in g apices
m on olatera l bracin g at t h e h u m er u s. Note t h e sepa rat ion of u sin g th e an tegrade m on olateral bracin g at th e h u m eru s.
th e apices at th e fractu re site a n d t h e n a il t ips in th e prox i- Again th e ben d in g apices are separated at th e fractu re site
m a l m etaph ysis.

10
 1.1 Bio m e ch a n ics

Ob t a in in g a n S-s h a p e d u rin g m a n ip u la t io n m an eu ver produ ces th e desired S-sh ape. Th e u se of th is tech -

To obtain th is special in n er bracin g, th e rst n ail is in serted n iqu e to produ ce th e secon d cu r ve of th e S-sh ape ( Fig 1.1-17d )
u sin g th e stan dard tech n iqu e ( Fig 1.1-17a ). Th rou gh a secon d du rin g th e m an ipu lation process m akes th e in sertion process
in sertion site, th e secon d n ail, wh ich h as been appropriately easier th an if th is secon d cu r ve was precou n tered.
preben t in th e d istal th ird, is in serted ( Fig 1.1-17b ). After th is
precon tou red portion h as been in serted com pletely in to th e
m edu llar y can al, th e n ail is rotated a fu ll 180 º ( Fig 1.1-17c). It
is im portan t at th is poin t to take care th at th e rst n ail is n ot
crossed tw ice. Th e portion of th e n ail still rem ain in g ou tside
th e bon e is n ow ben t forcefu lly in th e lon gitu d in al ax is. Th is

18 0 °

a b c d

Fig 1.1-17a – d Th e step-by-step description of sin gle-sided n ail

in sertion an d S-sh ape con gu ration .

11
 1 Ba s ic p rin cip le s

Pit fa lls – Pe a rls +

As a ru le, th e good-n atu red n ess of th e m eth od forgives It h as been em ph asized repeated ly th at lon g spiral an d
m an y failu res. However, errors m ay add u p. For exam ple, if com pletely u n stable fractu res can n ot be treated su f cien tly
you h ave an im proper in d ication com bin ed w ith th e w ron g w ith ESIN. If h owever, all biom ech an ical prin ciples are
tech n iqu e, th e resu lt cou ld be a m ajor problem , su ch as a followed correctly an d th e tech n iqu es described above are
delayed u n ion , a m alu n ion , or severe sh orten in g. applied, a proxim al spiral fractu re w ith spiral wedge can be
treated adequ ately.

Fig 1.1-18a–b Different tech n ical errors leadin g to failu re are Fig 1.1-19 a – f Th e fractu re pattern in th is fem u r in volved
demon strated in these AP and lateral x-rays: th e m idd le to prox im al 1/3 w ith a spiral wedge (32-D/5.2).
• Th e approach is in correct. Th e en tr y poin ts are too h igh . Th is is an absolu tely u n stable fractu re. However, by strictly
Th e tips of th e n ails are in th e w ron g position . applyin g th e basic pr in ciples of th e ESIN tech n iqu e, an
• Th ere is in adequ ate xation becau se of a lack of 3-poin t excellen t ou tcom e h as been ach ieved.
con tact. Distally, th ere is n o n ail con tact. Th e crossin g a – b In ju ry x-rays, AP an d lateral view s.
poin t is at th e level of th e fractu re. Th ere is a “corkscrew c– d AP an d lateral view s after 4 weeks sh ow align m en t
ph en om en on” as m an ifested by th ree crossin gs of th e w ith good callu s bridgin g.
n ails. e – f Follow-u p x-rays at 10 m on th s after im plan t rem oval,
• Th ere is a lack of stability becau se th e two n ails h ave n o dem on stratin g com plete rem odelin g AP an d lateral.
con tact w ith th e in n er cortex. Th ese tech n ical errors
h ave led to failu re as m an ifested by severe sh orten in g.

12
 1.1 Bio m e ch a n ics

Pit fa lls – (co n t) Pe a rls + (co n t)

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Th e m ost frequ en t pitfalls are: Th e follow in g steps are essen tial:
• Sh orten in g becau se of in su f cien t ax ial stability • Good preben din g of th e n ails, especially th e tips
• Rotation al failu res resu ltin g from n ot com parin g th e • Th e m ore proxim al th e fractu re site, th e greater is th e
postoperative rotation to th at of th e n on fractu red n eed to precon tou r th e n ail in its d istal th ird
extrem ity • By doin g th is, th e len gth of th e in side con tact can be
• Leavin g en ds of th e n ails too lon g; th is can produ ce exten ded. In add ition , th is sh ifts th e crossin g poin t to a
sk in perforation leadin g to a su bsequ en t in fection m ore proxim al position .
• Ax ial deviation as a resu lt of in stability cau sed by • Th e n ails sh ou ld n ot crisscross repeated ly (ie, produ cin g
– too th in n ails, a “corkscrew ph en om en on ”)
– corkscrew ph en om en on , • M iss-a-n a il tech n iqu e
– th e in sertion poin ts of th e n ails at differen t levels, • Addition al sm all extern al xator
– d ifferen t sizes of th e n ails, • En d caps
– d ifferen t n ail cu rvatu res

Re h a b ilit a t io n Re h a b ilit a tio n

If th ere is in adequ ate stability, th e ch ild can n ot be properly Wh en th e correct treatm en t is applied, n o add ition al im -
m obilized. m obilization for eith er th e lower extrem ity or th e u pper
extrem ity is n eeded. Fu n ction al postoperative m an age-
m en t is absolu tely m an dator y. Th e ch ild sh ou ld be able to
retu rn to h is or h er n orm al activities as soon as possible.

If sh orten in g occu rs, a secon d operation m ay be n ecessar y.

If th e fractu re is u n stable, extern al stabilization in th e form
of a cast or splin t m ay be n eeded.

13
 1 Ba s ic p rin cip le s

6 Su gge s t e d re a d in g

Brät e n M , Te rje se n T, Ro ssvo ll I (1993)

Torsion al deform ity after in ra m edu llary n ailin g of fem oral
sh aft fractu res. Measu rem en t of an teversion an gles in 110
patien ts.
J Bone Joint Surg Br; 75(5):799 –803.
Clin k scale s CM , Pe t e rso n H A (1997)
Isolated closed d iaph yseal fractu res of th e fem u r in ch ild ren :
com parison of effectiven ess an d cost of several treatm en t
m eth ods.
Orthopedics; 20(12):1131–1136.
Fly n J M , H re sko T, Re y n o ld s R A , e t al (2001)
Titan iu m elastic n ails for ped iatric fem u r fractu res: a m u lti-
cen ter stu dy of early resu lts w ith an alysis of com plication s.
J Pediatr Orthop; 21(1):4 –8.
Lin h art WE, Ro p o sch A (1999)
Elastic stable in tra m edu llary n ailin g for u n stable fem oral
fractu res in ch ild ren : prelim in ar y resu lts of a n ew m eth od.
J Trauma; 47(2):372 –378.
Me t aize au J P (1988)
Ostéosyn th èse ch ez l’en fan t Em broch age cen tro-m édu llaire
élastiqu e stable. Mon tpellier, Sau rarn ps Méd ical.
Sch m it te n be ch e r PP, D ie t z HG, Lin h art WE, e t al (2000)
Com plication s an d Problem s in In tram edu llary Nailin g of
Ch ild ren`s Fractu res. European Journal of Trauma; 6:287–293.
So la J, Sch o e n e cke r PL, Go rd o n J E (1999)
Extern al xation of fem oral sh aft fractu res in ch ildren :
en h an ced stability w ith th e u se of an au x iliary pin .
J Pediatr Orthop; 19(5):587–591.

14
1.2 Im plants and instrum e nts

Th e ESIN m eth od h as th ree u n iqu e qu alities:

1. It involves th e u se of a sim ple im plan t.
2. Th e tech n iqu e is ach ieved w ith a sim ple m eth od.
3. It requ ires on ly sim ple in stru m en ts.

1 Im p la n t d e s ign s a n d p ro p e r t ie s

Du a l fu n ct io n : im p la n t / t o o l
Th e elastic n ail plays a particu lar role. Th is special role of th e
n ail lies in th e fact th at, in con trast to oth er m eth ods, th e n ail
is prim arily a tool an d on ly secon darily does it fu n ction as an
im plan t. Th is is in deed a u n iqu e situ ation w h ich is n ot seen in
oth er system s of orth oped ic in stru m en tation .

Pre s e r vin g in d ivid u a l s t ru ct u re

It is im p o rta n t tha t e xce ssive m a nip u la tio n s du ring th e Fig 1.2 -1 Nail sizes.
in tro d u ctio n o r a d va n ce m e n t o f th e n a il a re a vo id e d . Nails are available in d iam eters of 1.5 –5.0 m m . Th ere are also
To o m u ch m a n ipu la tio n o f th e n a il ca n co m p le te ly alte r n ails w ith sm aller diam eters available. Th e h eigh ts of th e
its stru ctu re a n d b io m e ch a n ica l q u alitie s. Th e sa m e m a y in d ividu al n ail tips vary an d are determ in ed by th e d iam eter
o ccu r w ith th e in d ire ct re d u ctio n o f th e fractu re fra g- of th e n ail.
m e n ts. As a re su lt, th e stab ilizin g pro p e rtie s o f th e na ils
m a y b e lo st. Th e re fo re , it is o f gre a t im p o rta n ce th a t th e
su rge o n ca re fu lly fo llo w s th e p rin cip le s a n d te ch n iq u e s
d u rin g th e re d u ctio n a n d sta b iliza tio n p ro ce d u re s.

Tip o f t h e n a il Le n gt h o f t h e n a il
Th e special ben d of the tip of the n ail allows it to glide m ore Nails are available u p to 45 cm . Nails of som e produ cers h ave
easily. Th e form of th e tip also in su res th at the n ail h its and an u n iqu e len gth . Th u s, preoperatively th e desired len gth of
glides well at an appropriate an gle on th e con tralateral cortex. th e n ails does n ot n eed to be determ in ed. Th is allow s for m ore
precise placem en t of th e n ails. Oth er n ailin g system s are
Th e h eigh t of th e tip of th e n ail is adju sted to m atch th e diam - available w ith d ifferen t stan dard n ail len gth s accord in g to th e
eter of th e n ail. Th is gu aran tees th at th e h eigh t of th e tip w ill n ail diam eter.
also t properly w ith in th e m edu llary can al.

En d o f t h e n a il
Th e tip of th e n ail correspon ds w ith a m ark in g at th e en d of
th e n ail. Both are d irected an teriorly on th e n ail. Th is orien ta-
tion is provided so th e d irection of th e tip can be determ in ed
w ith ou t im age in ten si cation .

15
 1 Ba s ic p rin cip le s

En d ca p s (Fig 1.2-2)
2 In s t ru m e n t s
With very u n stable fractu res in older ch ildren th e axial stabil-
ity can be im proved by u sin g en d caps in cr itical situ ation s.
Th e u se of en d caps or sim ilar m ech an ism s in situ ation s w ith Becau se of th e u n iqu en ess of th e system , special in stru m en ts
axial in stability can h elp to preven t sh orten in g. Th is is u su ally are recom m en ded. To properly in sert th ese im plan ts, it is
accom plish ed w ith a d rill h ole at th e en d of th e n ail for lock- im portan t th at th e n ecessary in stru m en ts are available in th e
in g. To provide th ese altern ative m ech an ism s th e n ails h ave operatin g room .
to be of predeterm in ed len gth s
Han dlin g an d in sertion of th e im plan ts can fu n dam en tally be
im proved an d sim pli ed w ith th e h elp of th e in stru m en ts
speci cally design ed for ESIN tech n iqu e. Fu rth erm ore, th e
in stru m en ts h ave been carefu lly design ed so as to redu ce th e
tim e an d am ou n t of d irect ex posu re requ ired w ith th e im age
in ten si er.

Th e follow in g are illu strated exam ples of th e specialized

in stru m en ts u tilized to both in sert an d/or rem ove th e ESIN
im plan ts.

Aw l (Fig 1.2-3)
Th is is th e u su al an d m ost com m on in stru m en t to open th e
m edu llar y can al. Becau se th e m etaph yseal bon e is soft, it is
im portan t to rotate th e awl by h an d m ore th an 90 º to produ ce
an adequ ate open in g in th e bon e. In h ard bon e (eg, d istal
a b hu m eru s) it can be tapped in w ith a h am m er or a drill can be
u sed altern atively.

Fig 1.2 -3 Aw l for open in g th e bon e.

Th e h an d awl is u sed to create th e in sertion
Fig 1.2 -2 a – d
sites.
a En d cap(s).
b En d cap m ou n ted
on in sertion h an d le.
c– d Clin ical exam ples.

16
 1.2 Im p la n t s a n d in s t ru m e n t s

In s e r t e r/ T-h a n d le (Fig 1.2-4) 1. Th e asym m etrical T-piece can be align ed w ith th e tip of th e
Th e in serter is th e prim ar y in stru m en t u sed w ith th e n ails. It n ail to h elp w ith its orien tation .
facilitates n ail gu idan ce as it is in serted an d advan ced. It is 2. Th ere are add ition al laser m ark in gs on th e ch u ck to in d i-
con stru cted so th at th e h am m er can strike d irectly on th e at cate th e d irection of rotation n eeded to tigh ten or loosen
su rface of th e h an d le. th e ch u ck.
If th is special in serter is n ot available, a n orm al T-h an d le
Ha m m e r b lo w s d ire ctly to th e p ro tru d in g in se rte r/ chu ck can be u sed.
T-ha nd le m u st b e a vo ide d .
Ha m m e r (Fig 1.2-5)
Th ere are two special m od i cation s in its con stru ction th at Th e com bin ed h am m er (com bin ation of a n orm al an d a slot-
m ake n ail in sertion m ore sm ooth er, th u s decreasin g im age ted h am m er) can be u sed for in sertion as well as for rem oval
in ten si er tim e. of th e n ails. Th e slotted part is n orm ally u sed in com bin ation
w ith a h am m er gu ide.

Fig 1.2 -4 In serter. Fig 1.2 -5 Ham m er.

Th e h an d ch u ck is u sed to h old th e n ails Th e com bin ed h am m er h as a du al fu n c-
as th ey are in serted. Th e lon ger h an d le tion . Th e h ead is u sed to advan ce th e
sh ou ld be orien ted in th e sam e direction n ails in to th e bon e. Th e slotted sh aft
as th e n ail tip. Th e d irection to open th e can be u sed w ith th e h am m er gu ide to
chu ck is laser prin ted on th e chu ck. extract th e n ails.

17
 1 Ba s ic p rin cip le s

Ha m m e r gu id e (Fig 1.2-6) Im p a ct o r (Fig 1.2-7 )

If a h am m er is n eeded or th e n ail h as to be m oved forwards or A beveled im pactor is provided for th e de n itive placem en t of
backwards to redu ce th e fractu re, a h am m er gu ide is provided. th e n ail. Th e 8 m m h ole an d th e beveled tip gu aran tees th at
Th is h am m er gu ide can be screwed in to th e h an d le of th e th e correct len gth of th e n ail protru des from th e cortex to
in serter. It is u sed as a gu ide for th e slotted h am m er ( Fig 1.2-6 b ). en su re n ail rem oval.
Altern atively, th e h ead of th e h am m er can be stru ck d irectly
again st th e at su rface of th e base of th e h am m er gu ide.

Fig 1.2 -7 Im pactor.

Th is device w ith a lon g tu bu lar stru ctu re an d a recessed h ole
in on e en d is u sed for th e n al im paction of th e n ail deep in
th e soft tissu es wh en th e h am m er h ead can n o lon ger be u sed.
Th e at en d is u sed to drive in th e n ail over a lon g d istan ce.
Th e oth er en d h as an 8 m m h ole an d a beveled tip to en su re
a th at th e correct len gth of th e n ail protru des from th e cortex.

Na il cu t t e r (Fig 1.2-8)
To shorten the n ails a special cuttin g in stru ment is available.
Care mu st be taken to en su re th at the correct open in g is u sed
wh ich correspon ds to th e proposed n ail diameter. Th is n ail cut-
ter can be u sed very close to the skin w ithou t dan ger of dam ag-
in g the soft tissues. If the special cu ttin g in stru ment is not avail-
able, then a standard bolt cu tter can be u sed. In th is case the n ail
h as to be cut outside the incision to preven t soft-tissue dam age.

Fig 1.2 -6 a – bHam m er gu ide.

It can be applied to th e h an dle of eith er th e chu ck or extrac-
tion pliers.
a Th e gu ide screw s in to th e base of th e h an d le.
b Th e com bin ation h am m er can str ike th e gu ide base d irectly Fig 1.2 -8 Nail cu tter.
(arrow) to d rive th e n ail in to th e bon e. Altern atively, th e Th is device cu ts th e n ails by a rotation al m otion of th e h an -
h am m er can be slid alon g th e tu be of th e gu ide (arrow) to dles. Th is allow s th e n ail to be cu t u n der or ver y close to th e
strike th e top su rface of th e base for extraction of th e sk in w ith ou t in ju r y to th e wou n d m argin s.
n ail.
18
 1.2 Im p la n t s a n d in s t ru m e n t s

Ext ra ct io n p lie rs (Fig 1.2-9) F-t o o l (Fig 1.2-10)

Rem oval of th e n ail can be very d if cu lt. Th erefore, it is Th is special tool can be u sed to in d irectly apply redu cin g
im portan t to h ave a good rem oval in stru m en t. Th ese special leverage forces to th e su rface of a lim b su spen ded in traction
pliers are design ed to be able to gain a good grip on th e sh ort to secu re a n al redu ction . It is con stru cted of fou r rad iolu -
protru d in g en d of th e n ail. Th is is essen tial becau se of th e cen t parts wh ich form th e letter F wh en pu t togeth er. Th e
forces requ ired to extract a n ail th at was im plan ted for a lon g m ain portion is a lon g th in rectan gu lar piece w ith screw h oles
tim e. Th e h an d les of th e pliers are con stru cted in su ch a way placed at strategic d istan ces. Th ere are th ree separate sh ort
th at th e su rgeon can u se d ifferen t m eth ods to apply th e rou n d pieces th at can be screwed in to th e h oles depen d in g on
extractin g forces. Th e rst option is to str ike th e h am m er th e th ick n ess of th e extrem ity. Two of th ese pieces are in serted
d irectly again st th e little protru d in g arm on th e h an d le. Th e in to on e en d at th e appropriate d istan ce to lie on th e an terior
secon d option is to screw th e h am m er gu ide in to th e h an d le an d posterior su rfaces of th e extrem ity. Th e oth er rou n d piece
an d u se th e slotted h am m er. If th ese special extraction pliers is screwed in to th e oth er en d protru d in g in th e opposite d irec-
are n ot available, ord in ary at-n osed pliers can be u sed. tion . Th is piece can be u sed as a h an d le to apply th e appropri-
ate leverage force to th e extrem ity an d in directly again st th e
fractu re en ds to ach ieve th e n al redu ction .

Alt e rn a t ive in s t ru m e n t s
Altern atively, oth er in stru m en ts are available to apply th e
ESIN prin ciples an d tech n iqu es.

Fig 1.2 -9 Extraction pliers. Fig 1.2 -10 Rad iolu cen t F-tool.
Th is tool grasps th e en d of th e n ail very rm ly to facilitate Leverage forces can be applied to th e sk in of th e lim b by raisin g
its extraction . Th e extractin g force can be applied by eith er th e h an dle of th is rad iolu cen t tool. Th is brin gs th e fractu re
strik in g d irectly th e protru d in g arm on th e plier h an d le or fragm en ts in to a better align m en t to facilitate n ail passage.
u sin g th e slotted h an d le alon g th e gu ide.

19
 2 Hum e rus

2 .1 In t ro d u ct io n —h u m e ra l fra ct u re s 21
1 In d ica tio n 21
2 Pa tie n t p re p a ra tio n a n d p o sitio n in g 21
3 Su rgica l p rin cip le 2 3
4 Im p la n t re m o va l 24
5 Su gge ste d re a d in g 24

2 .2 Pro xim a l h u m e ra l fra ct u re , co m p le t e ly d is p la ce d

(11-M/ 4 .1) 2 5

2 .3 Hu m e ra l s h a ft fra ct u re , s p ira l, d is p la ce d , a n d
u n s t a b le (12 -D/ 5 .1) 31

2 .4 Hu m e ra l s h a ft fra ct u re , t ra n s ve rs e , d is p la ce d
(12 -D/ 4 .1) 37

20
2.1 Introduction —hum e ral fracture s

1 In d ica t io n

Su b ca p it a l h u m e ra l fra ct u re s However, becau se axial deviation s of m ore th an 10 º ten d to

Age is n ot a factor in determ in in g th e in d ication for su rgical produ ce a cosm etically m alalign ed arm , su rgical stabilization
stabilization of com pletely d isplaced fractu res. In patien ts u n - is often in d icated. Oth er in d ication s are:
der 10 years, fractu res w ith an ax ial deviation of m ore th an Fractu res in polytrau m atized ch ild ren .
30° varu s, an te- or recu rvatu re, or m ore th an 10° valgu s n eed Ipsilateral fractu res of th e hu m eru s an d forearm .
su rgical stabilization to ach ieve an d m ain tain adequ ate align - Accom pan yin g fractu res of a lower extrem ity wh ere
m en t. th ere is n eed to u se cru tch es.
Open fractu res Gu stilo type II an d III.
In patien ts older th an 10 years, an y ax ial deviation of greater Path ological fractu res or an y gen eralized disease th at ren -
th an 10° in an y of th e varu s, an te- or recu rvatu re plan es is an ders con servative treatm en t im possible.
in d ication for su rgical stabilization . Oth er very speci c in d i-
cation s wou ld be in th e m an agem en t of path ological fractu res Ra d ia l n e r ve d ys fu n ct io n
(ie, ju ven ile bon e cysts) or in th e polytrau m atized ch ild to fa- Th e patien t w ith a prim ar y weak n ess of th e rad ial n er ve m ay
cilitate m an agem en t in an in ten sive care u n it settin g (ICU). ben e t from su rgical stabilization to facilitate th e in itiation
of im m ediate ph ysical th erapy. However, an im m ediate open
Hu m e ra l s h a ft fra ct u re s redu ction of th e fractu re w ith n erve ex ploration is n ot in d i-
Fortu n ately, in th e u pper arm , m alalign m en t rarely creates cated in th is situ ation becau se th ere is u su ally spon tan eou s
an y fu n ction al loss. Th e exibility of th e sh ou lder allow s m ost recovery of rad ial n er ve fu n ction .
an gu lar or rotation al m alalign m en t to be com pen sated.

2 Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Em ergen cy treatm en t of th ese fractu res is u su ally reser ved for In d ication s for th rom bosis proph ylax is are lim ited to over-
open fractu res, vascu lar in ju ries, or gen eral con d ition s wh ere weigh t ch ild ren or postm en arch al girls tak in g birth con trol
an im m ed iate operation wou ld be n ecessar y. m edication . An oth er in dication wou ld be if im m obilization
were n ecessar y for gen eral con dition s su ch as polytrau m a,
Me d ica t io n in ju ries of th e lower extrem ity or pelvis, or severe n on trau -
An tibiotic prophylaxis is recom m en ded for open fractu res m atic illn ess.
on ly. For closed fractu res it sh ou ld con form to th e stan dard of
care of clin ical protocol.

21
 2 Hu m e ru s

2 Pa t ie n t p re p a ra t io n a n d p o s it io n in g (co n t)

Pa t ie n t p o s it io n in g
Th e patien t is placed su pin e w ith th e in ju red extrem ity on
an arm table ( Fig 2 .1-1a ). In su bcapital fractu res th e sh ou lder
n eeds to be position ed in side th e table to preven t th e m etal
edge of th e table in terferin g w ith th e im age. In sh aft fractu res
th e patien t n eeds to be placed as lateral as possible so th at an
u n d istu rbed im age of th e fractu re region can be obtain ed.

Altern atively, th e arm is position ed on th e su rgical table par-

allel to th e patien t’s body ( Fig 2 .1-1b ). Th is facilitates th e en tire
a
process of im age in ten si cation wh ich can be perform ed
w ith in th e con n es of th e table for both su bcapital an d sh aft
fractu res.

Th e en tire u pper extrem ity in clu d in g th e sh ou lder is prepared

an d draped. Th e h an d is covered w ith a su rgical glove. It is in -
su f cien t to prepare an d d rape ou t on ly th e su rgical en tran ce
area arou n d th e elbow.

Eq u ip m e n t
Stan dard ESIN set.
Power dr ill.
Th e u se of a d rill is option al, it m igh t be n ecessar y be-
cau se perforation of th e den se cortical bon e of th e d istal
hu m eru s w ith an awl alon e m ay be dif cu lt to accom -
plish .
Nails: b
– 2.0 –3.0 m m stain less steel or titan iu m ;
– 1/ 3 of th e d iam eter of th e m edu llar y can al at th e Fig 2 .1-1a – b
m id-diaphyseal region . a Position in g w ith an arm table. For sh aft fractu res th e arm
– Both n ails m u st be of th e sam e size. lies on th e arm table.
– Stain less steel n ails are preferred in older ch il- b Position in g w ith th e operatin g table. For su bcapital
dren becau se th e resistan ce to friction w ith in th e fractu res th e sh ou lder sh ou ld lie in side th e table. All th e
m edu llar y can al of th e hu m eru s is ver y h igh . im agin g is perform ed in side th e operatin g table.
Im age in ten si er.

22
 2 .1 In t ro d u ct io n —h u m e ra l fra ct u re s

3 Su rgica l p rin cip le

Dire ct io n o f n a ilin g in p ro xim a l fra ct u re s Dire ct io n o f n a ilin g in s h a ft fra ct u re s

Em ploy retrograde n ailin g u sin g a lateral en try poin t d istally In th ose fractu res in volvin g th e m idd le an d prox im al th ird of
as th is requ ires on ly on e in cision w ith two en try poin ts in th e th e d iaph ysis, u se retrograde n ailin g, em ployin g both lateral
cortex ( Fig 2 .1-2 a ). an d m ed ial en try poin ts ( Fig 2 .1-2b ). In th ose in volvin g th e
d istal th ird of th e d iaph ysis, u se an tegrade n ailin g th rou gh
on e sin gle lateral su bdeltoid approach for both n ails w ith two
en tran ce poin ts in th e cortex ( Fig 2 .1-2c).

a b c

Fig 2 .1-2 a – c Nail in sertion tech n iqu es.

a Retrograde on e side (lateral). b Retrograde both sides (m ed ial c An tegrade on e side (lateral).
an d lateral).

23
 2 Hu m e ru s

4 Im p la n t re m o va l

Pro xim a l fra ct u re s Sh a ft fra ct u re s

If th ere was perforation of th e epiphyseal plate, an X-rays are taken 3 m on th s after su rger y. If th ere is fu ll con solidation
x-ray is taken 6 –8 weeks after su rger y. If th ere is an d rem odelin g of th e bon e, th e n ails m ay be rem oved ( Fig 2 .1-4 ). If
good bon y con solidation , th e n ails can be rem oved con solidation an d rem odelin g are in adequ ate, th en n ail rem oval sh ou ld
( Fig 2 .1-3 ). be postpon ed. Prem atu re rem oval sh ou ld be perform ed on ly if th ere are
sk in irritation problem s arou n d th e en tran ce poin ts.

a b a b

X-ray of a su bcapital fractu re sh ow-

Fig 2 .1-3 a – b Lateral an d AP x-rays of a sh aft
Fig 2 .1-4 a – b
in g con solidation an d rem odelin g. fractu re sh ow in g con solidation an d rem odelin g.

5 Su gge s t e d re a d in g

Gau t ie r E, Slo n go T, Jako b R P (1992) Sch m it t e n be ch e r PP, Blu m J, D av id S, e t al (2004)

Treatment of su bcapital hu m eru s fractu re w ith the Prevot n ail. Treatment of hu meral sh aft and su bcapital fractu res in ch il-
Z Unfallchir Versicherungsmed; 85(3):145 –155. dren . Con sen su s report of the ch ild trau m a section of the DGU.
Hav ran e k P, Pe sl T (2002) Unfallchirurg; 107(1):8 –14.
Use of th e elastic stable in tram edu llary n ailin g tech n iqu e in Sch w e n d e nw e in E, Hajd u S, Gae ble r C, e t al (2004)
n on -typical pediatric fractu res. Displaced fractu res of th e prox im al h u m eru s in ch ild ren
Acta Chir Orthop Traumatol Cech; 69(2):73 –78. requ ire open /closed redu ction an d in tern al xation .
Mach an FG, Vin z H (1993) Eur J Pediatr Surg; 14(1):51–55.
Hu m eral sh aft fractu re in ch ildh ood. Se ssa S, Lasco m be s P, P re vo t J, e t al (1990)
Unfallchirurgie; 19(3):166 –174. Cen tro-m edu llar y n ailin g in fractu res of th e u pper en d of
Sch it t ko A (2003) th e h u m eru s in ch ild ren an d adolescen ts.
Hu m eru s sh aft fractu res. Chir Pediatr; 31(1):43 –46.
Unfallchirurg; 106(2):145 –160.

24
2.2 Proxim al hum e ral fracture , com ple te ly displace d (11-M/ 4.1)

1 Ca s e d e s crip t io n

A 14-year-old m ale fell from a tree lan din g directly on h is left

sh ou lder. Clin ically, h e presen ted w ith sign i can t swellin g of th e
sh ou lder com bin ed w ith pain fu l restr iction of m otion . Th e x-rays
dem on strated a closed com pletely d isplaced tran sverse fractu re of
th e prox im al m etaph ysis of th e left h u m eru s.

Fig 2 .2 -1a – b AP an d tran sscapu lar Y x-rays of th e fractu red

a b
hu m eru s.

2 Su rgica l a p p ro a ch

Sk in in cis io n
In cise th e sk in at th e lateral aspect of th e d istal h u m eru s. If
possible, it is recom m en ded th at a m ed ial en tran ce site sh ou ld
be avoided becau se of th e r isk of u ln ar n erve in ju r y. Begin
th e in cision 1 cm above th e palpable prom in en ce of th e lateral
epicon dyle an d progress 3 –4 cm proxim a lly (cran ially) u p th e
lateral aspect of th e hu m eru s.

3 – 4 cm Ap p ro a ch
Spread th e su bcu tan eou s tissu e to ex pose th e fascia. Blu n t d is-
1 cm
section th e fascia to expose th e lateral su pracon dylar ridge of th e
distal hu m eru s, tak in g care to rem ain on th e an terior side of th e
in tram u scu lar septu m . Sh ar p open in g of th e periosteu m an d
su bperiosteal preparation to avoid in ju r in g th e rad ial n erve.

Fig 2 .2 -2 Th e sk in is in cised for 3 –4 cm over th e lateral aspect

of th e distal hu m eru s startin g abou t 1 cm proxim al to th e
prom in en ce of th e lateral con dyle.

25
 2 Hu m e ru s

2 Su rgica l a p p ro a ch (co n t)

Na il in s e r t io n
On ce th e bon e is ex posed, place an awl at th e cran ial en d of in ser tion site w ith th e aw l in th e sa m e m a n n er as th e rst
th e in cision 90 º to th e lateral cortical su rface. Care m u st be ( Fig 2 .2-4 a ).
taken wh en d r illin g w ith th e aw l to avoid slippin g off th e lat-
eral cortex. If th e awl progresses easily in to th e lateral cortex, Once th is entrance site is com pleted, introduce the n ail and ad-
it is sh ifted cran ially to a position of 45º. Progressively drill vance it proxim ally to the diaphyseal region . If the cortical bone
w ith th e aw l u n til it en ters th e m edu llar y cavity ( Fig 2 .2-3 ). is very h ard, a drill shou ld be u sed to m ake the in sertion sites.

In trodu ce th e rst n ail an d advan ce it prox im ally to th e Both n ails are advan ced proxim ally to lie ju st distal to th e
d iaph ysea l region . Dr ill w ith th e aw l a secon d tim e 1–2 cm fractu re site. It is very im portan t to gu ide th e n ails so th at
cau da l (d istal) an d approx im ately 1 cm a n ter ior of th e rst th ey are n ot tw isted on e arou n d th e oth er (corkscrew ph en o-
in ser tion site. Lean th e aw l again st th e rst n ail to ser ve as a m en on). Th e tips of th e n ails are d irected at 90 º to th e fractu re
gu ide a n d keep it from slippin g. Con tin u e by d r illin g a secon d lin e ( Fig 2 .2-4b ).

a b

Fig 2 .2 -3 First en tran ce site. Fig 2 .2 -4 a – b

Th is is u su ally th e prox im al site. Th e aw l is started a First an d secon d n ail. Th e rst n ail is in serted th rou gh its en tran ce
rst at 90° u n til it en gages th e cortex. It is th en gra- site an d advan ced proxim ally. Th e secon d en tran ce site is th en m ade
du a lly tilted to 45° as it drills th rou gh th e cortex. d istally an d an teriorly w ith th e aw l. Th e h an d le of th e awl is lean ed
again st th e rst n ail to gu ide it u n til it h as pen etrated th e cortex.
b Th e secon d n ail is in serted an d both n ails are advan ced prox im ally to
th e fractu re site.

26
 2 .2 Pro xim a l h u m e ra l fra ct u re , co m p le t e ly d is p la ce d (11-M/ 4 .1)

3 Re d u ct io n a n d fixa t io n

Re d u ct io n in directly ( Fig 2 .2-5b ). Som etim es it m igh t be h elpfu l to in sert

Redu ce th e fractu re by applyin g d istal traction to th e exten d- a n ail percu taneou sly into the epiphysis an d u se it as a joystick
ed u pper extrem ity. Usin g cou n tertraction w ith a towel placed to m an ipu late the epiphysis into the proper position .
u n der th e ax illa, d istal traction is con tin u ed u n til len gth
h as been reestablish ed. Fractu re redu ction is com pleted by Fin a l p la ce m e n t
abdu ctin g th e arm to lin e u p th e fractu re su rfaces of th e prox- Make su re th at th e tips of th e n ails are in d ivergen t position s.
im al an d distal fragm en ts ( Fig 2 .2-5 a ). Th e position s of both n ails are con rm ed an d n ail perforation
is exclu ded by tak in g th e prox im al h u m eru s th rou gh a fu ll
St a b iliza t io n ran ge of m otion u sin g real tim e im agin g. Th ere n eeds to be
Once a satisfactory reduction h as been ach ieved, advance the free articu lar m ovem en t w ith ou t an y restriction . If th e redu c-
rst n ail proxim ally in to th e epiphysis w ith ou t any con cern tion an d stability are satisfactor y, th e n ails are cu t d istally so
abou t perforatin g th e physis. Do n ot forget th at on th e AP th e tips lie deep w ith in th e su bcu tan eou s tissu e ( Fig 2 .2-5 c).
im age th e hu m eral h ead is in an obliqu e position in relation
to the sh aft. If the position of the hu m eral head is not perfect, Th e wou n d is closed w ith sin gle su tu res.
tu rn the n ail to correct the position of the proxim al fragm en t

18 0 °

90°

a b c

Fig 2 .2 -5 a – c
a Reduction an d xation . The fractu re is reduced by brin gin g b Th e rst n ail is advan ced prox im ally in to th e prox im al
the distal fragm ent into abduction . One n ail is advan ced fragm en t. Th e tip of th is n ail can also be rotated (circu lar
in to th e proxim al fragm en t. Som e correction of th e redu c- arrow) to im prove th e fractu re align m en t.
tion can be ach ieved by rotatin g the second n ail (circu lar c Fin al position . On ce both n ail tips h ave been secu red in
arrow). th e h ead, th e pin s are cu t d istally. Notice th e tips h ave th e
desired divergen ce.

27
 2 Hu m e ru s

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Ea rly m o t io n He a lin g
No add ition al extern al protection is n ecessar y. Free m ove- Th e rst follow-u p x-rays are taken at 4 weeks ( Fig 2 .2-6 c– d ).
m en t is allowed im m ed iately depen d in g on th e degree of If th ere is adequ ate callu s form ation , th en sports activities can
postoperative pain w ith n o restriction s con cern in g th e ran ge be resu m ed. Th e n al x-rays are taken 8 weeks later to ch eck
of m otion . for fu ll rem odelin g ( Fig 2 .2-6 e – f). At th is tim e im plan t rem ov-
al can be plan ed as an ou tpatien t procedu re.
Th e patien t can be disch arged after th e x-rays h ave been taken
on th e rst postoperative day to en su re th at th e redu ction
h as been m ain tain ed ( Fig 2 .2-6 a – b ). No physioth erapy is re-
qu ired.

a b c d e f

Fig 2 .2 -6 a – f
a – b Postoperative AP an d lateral x-rays dem on stratin g excellen t position in g of th e n ail tips
in th e prox im al fragm en t.
c– d AP an d lateral x-rays at 4 weeks sh ow early callu s form ation .
e – f AP an d lateral x-rays 8 weeks postoperatively dem on strate th e m atu red callu s.

28
 2 .2 Pro xim a l h u m e ra l fra ct u re , co m p le t e ly d is p la ce d (11-M/ 4 .1)

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n (co n t)

Fig 2 .2 -7a – cMotion reestablish ed. Th ree view s

taken at 12 weeks dem on stratin g fu ll recover y of
a b c
sh ou lder m otion . Fu ll physical activity is allowed.

5 Alt e rn a t ive ca s e —t yp e 12 -D/ 4 .1

Even in sm aller ch ildren , exactly th e sam e tech n iqu e of in - Th e fractu re was stabilized u sin g th e retrograde ESIN tech -
tram edu llary stabilization is u sefu l. A 9-year-old boy fell from n iqu e ( Fig 2 .2-8 b ). As th e fractu re h ealed, h e was able to
a tree su stain in g an in ju ry to h is left sh ou lder area. X-ray gain early recovery of both m otion an d stren gth in th e u pper
taken in th e em ergen cy room revealed a com pletely dis- extrem ity Fig 2 .2-8 c).
placed fractu re at th e proxim al hu m eral diaphysis ( Fig 2 .2-8 a ).

a b c

Fig 2 .2 -8 a – c
a Displaced fractu re of th e prox im al h u m eral d iaph ysis w ith
sh orten in g an d bayon et apposition .
b Postoperative x-ray sh ow in g good redu ction an d place-
m en t of th e n ail tips.
c 8 weeks postoperatively su f cien t callu s is visible an d n ail
rem oval can be con sidered.

29
 2 Hu m e ru s

6 Pit fa lls – 7 Pe a rls +

Ap p ro a ch Ap p ro a ch
In cision too prox im al w ith th e risk Fig 2 .2 -12 Especially in sm all ch ildren , start th e sk in
of radial n erve in ju ry. in cision 1 cm above th e lateral epicon dylar prom in en ce
to be as d istal as possible from th e rad ial n erve.

3 – 4 cm

1 cm

Fig 2 .2 -9 Th e h igh en try poin t of th e

n ails resu lted in a paresis of th e radial
n erve postoperatively an d add ition ally
on e n ail is perforatin g th e cortex.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Fig 2 .2 -10 X-rays dem on strate a poor Make su re th e en tire hu m eral h ead is
Fig 2 .2 -13 a – b
t of th e n ail tips w ith pen etration of in spected w ith th e im age in ten si er. Rotate th e u pper
th e h ead (arrow extrem ity 180 º to con rm th at sh ou lder m otion is free
an d dotted lin e). an d com plete.

a b

Re h a b ilit a t io n Re h a b ilit a t io n
Fig 2 .2 -11Nail en ds are too lon g produ cin g a risk Su f cien t cu ttin g of th e n ails: it is best to w ith draw
of sk in perforation an d/or irritation w ith blockage of th e n ails a few m illim eters before cu ttin g th em an d th en
elbow ex ion . rein ser tin g th em proxim ally.

30
2.3 Hum e ral shaft fracture , spiral, displace d, and unstable
(12-D/ 5.1)
1 Ca s e d e s crip t io n

A 6-year-old girl fell break in g h er fall w ith h er righ t ou t-

stretch ed arm . Th e extrem ity was pain fu l w ith an obviou s
d isplacem en t in th e region of th e h u m eral sh aft. Clin ically,
th ere was in tact sk in w ith a fu n ction in g rad ial n erve.

X-rays dem on strated a spiral fractu re exten din g from th e

m iddle to th e distal th ird of th e left hu m eral d iaph ysis.
Th e fragm en ts were displaced in to an tecu r vatu re an d var-
u s ( Fig 2 .3 -1). Clin ically, th is fractu re pattern was felt to be
u n stable.

Fig 2 .3 -1a – bAP an d lateral x-rays of th e righ t arm sh ow in g

a lon g spiral fractu re of th e h u m eral sh aft w ith an terolateral
a b
apical an gu lation .

31
 2 Hu m e ru s

2 Su rgica l a p p ro a ch

Sk in in cis io n Na il in s e r t io n
Make a lateral 3 –4 cm lon g in cision at th e cau dal edge of In t rodu ce t h e n a il in to t h e m edu lla r y ca n a l a n d adva n ce
th e d istal portion of th e deltoid mu scle. It is im portan t n ot to it d ist a lly to t h e fract u re region . Place t h e aw l a secon d
in cise too d istally to avoid in ju rin g th e rad ial n er ve. Th e su b- t im e aga in st t h e bon e 1–2 cm prox im a lly a n d eit h er a lit t le
cu tan eou s tissu e an d th e fascia are split to ex pose th e bon e. a n ter iorly or poster iorly to t h e fir st p er forat ion . Lea n t h e
aw l aga in st t h e fir st n a il to gu ide it in t h e proper d irec-
Pro xim a l in s e r t io n s it e s t ion . Con t in u e d r illin g t h e secon d en t ra n ce site w it h t h e
Place th e aw l at th e cau dal en d of th e in cision per pen d icu lar aw l to produ ce a n obliqu e d ist a lly d irected d r ill h ole in to
to th e bon e to in itiate drillin g th e rst en tran ce h ole. On ce t h e m edu lla r y ca n a l. In ser t t h e secon d n a il ( Fig 2 .3 -2 b ) a n d
th e awl en gages th e cortical bon e, m ove it to a 45° an gle to th e adva n ce it d ist a lly to t h e fract u re lin e. Rot ate t h is secon d
lon g ax is of th e bon e to en ter th e m edu llary can al ( Fig 2 .3 -2 a ). n a il 18 0 ° so t h at t h e t ip is d irected m ed ia lly a n d d ivergen t
Becau se th e cortical bon e in th is area m ay be too h ard to h an d to t h e fir st n a il t ip ( Fig 2 .3 -2 c).
drill w ith th e awl, an electr ic drill can be u sed to create th e
en tran ce sites.

18 0 °

a b c

Fig. 2 .3 -2 a – c Prim ary n ail in sertion . b Th e n ails are in serted in to th eir respective en tran ce sites
a Th e in cision is placed at th e cau dal d istal edge of th e deltoid an d advan ced distally towards th e fractu re.
m u scle. An aw l is u sed to create th e en tran ce sites on th e c On ce th e fractu re h as been reach ed, th e prox im al n ail is
lateral an d an terior su rfaces of th e cortex. rotated 180 º (circu lar arrow) so th at its tip is d ivergen t to
th at of th e d istal n ail.

32
 2 .3 Hu m e ra l s h a ft fra ct u re , s p ira l, d is p la ce d , a n d u n s t a b le (12 -D/ 5 .1)

3 Re d u ct io n a n d fixa t io n

Dire ct a n d in d ire ct re d u ct io n Fra ct u re s t a b iliza t io n

Th e d istal fragm en t is secu red by th e h an d of an assistan t wh o Now orien t both n ails correctly to preven t th e corkscrew
applies sligh t traction . Th en th e n ails are u sed like h an d les to ph en om en on an d advan ce th em distally to th e radial an d
brin g th e proxim al fractu re su rface in to con tact w ith th at of u ln ar su pracon dylar colu m n s ( Fig 2 .3 -3 c). Rotate th e n ails
th e d istal fragm en t by d irect m an ipu lation . Wh ile th e redu c- sligh tly to carefu lly align th e exact position s of th e apices of
tion is bein g m ain tain ed, advan ce th e m ore easily in serted th e ten sion ben ds so th e align m en t ach ieves a perfect spread-
n ail in to th e distal fragm en t ( Fig 2 .3 -3 a ). Attem pt to im prove in g of th e n ails at th e fractu re level. Now secu re th e n ails in
th e redu ction by rotatin g th e tip of th e rst n ail to ach ieve an th e stron g m etaph yseal bon e by a few h am m er blow s to th e
in d irect redu ction . Advan ce th e secon d n ail in to th e d istal beveled im pactor or directly on th e n ails en ds. Fin ally, cu t th e
m edu llar y can al ( Fig 2 .3 -3b ). To preven t an y secon dary rad ial n ails an d place th e en ds in th e su bcu tan eou s tissu e. Close th e
n erve in ju ry, take care th at th e n ails do n ot leave th e m edu l- sk in w ith 1 or 2 sin gle su tu res ( Fig. 2 .3 -3 d ).
lar y can al th rou gh th e fractu re in to th e su rrou n d in g tissu e.

a b c d

Fig. 2 .3 -3 a – d Redu ction an d stabilization . b Th e secon d n ail is advan ced across th e fractu re site.
a As an assistan t stabilizes th e d istal fragm en t, th e n ails are c Th e tips of both n ails are advan ced in to th e su pracon dylar
in serted in to th e prox im al fragm en t. Th ese n ails can be colu m n s. Fin al stabilization is ach ieved by d r ivin g th e n ail
u sed to m an ipu late th is fragm en t to ach ieve a satisfactor y tips in to th e solid m etaph yseal bon e.
redu ction . On ce redu ced, on e of th e n ails is advan ced in to d After th e n ails h ave been cu t, th e in cision is closed w ith a
th e d istal fragm en t. few su tu res.

33
 2 Hu m e ru s

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Becau se of th e stability ach ieved, th e ch ild can begin u n - tion is accom plish ed ( Fig 2 .3 -4 a – b ). Follow-u p x-rays 4 weeks
restricted active sh ou lder m otion im m ediately follow in g postoperatively sh ou ld dem on strate su f cien t callu s to perm it
su rger y. No postoperative extern al su pport is n eeded. Norm al participation in sports activities ( Fig 2 .3 -4 c– d ). 3 m on th s after
postoperative pain a n d swellin g cau ses som e of th e ch ildren su rger y, th e callu s sh ou ld h ave u n dergon e su f cien t rem od-
to be relu ctan t to in itiate m u ch in th e way of active m otion for elin g an d be con solidated en ou gh to con sider n ail rem oval
a few days. Pr ior to d isch arge postoperative x-ray docu m en ta- ( Fig 2 .3 -4 e – f).

a b c d e f

Fig 2 .3 -4 a – f
a – b AP an d lateral x-rays at d isch arge c– d AP an d lateral x-rays at 4 weeks e –f X-rays taken 3 m on th s postopera-
dem on strate satisfactory position - postoperatively dem on strate good tively dem on strate su f cien t h eal-
in g of th e n ails. callu s su rrou n din g th e fractu re in g an d rem odelin g to con sider
site. n ail rem oval.

34
 2 .3 Hu m e ra l s h a ft fra ct u re , s p ira l, d is p la ce d , a n d u n s t a b le (12 -D/ 5 .1)

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Th e su bdeltoid en tra n ce site in sm all ch ild ren m ay be In sm a ll ch ildren som etim es it m ay be best to u se a
too close to th e fractu re site to per m it stable redu ction of tran sdeltoid approach or a n retrograde approach .
th e fractu re.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
In su f cien t spreadin g of th e n ails m ay in adequ ately align th e At th e en d of th e operation it is im perative to ch eck th e n al
fragm en ts. position of th e fragm en ts w ith th e im age in ten si er by
rea l-tim e visu alization . A n al correction m ay be ach ieved
by sligh t rotation of th e n ails.

Iatrogen ic radia l n er ve in ju r y ca n resu lt from : If follow in g th e n a ilin g procedu re, th ere is postoperative
• In ju r y by th e n ail(s) du r in g in ser tion rad ia l n er ve paralysis, th e n a il sh ou ld be replaced.
• Fixation of th e n er ve w ith in th e fractu re site At th e sa m e tim e th ere sh ou ld also be a n open su rgica l
in spection of th e n er ve.

35
 2 Hu m e ru s

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Re d u ct io n a n d xa t io n (co n t)
Spiral fractu res of th e h u m eru s also can be stabilized fau lt-
lessly at a correct application of th e ESIN tech n iqu e.

a b c d

e f g h

Fig 2 .3 -5a – h13-year-old fem ale w ith w rin g in ju r y an d

n ervu s radialis irritation .
a – b AP an d lateral in ju ry x-rays.
c– d Postoperative x-rays.
e – f Postoperative x-rays after 10 weeks.
g– h Follow-u p x-rays after 6 m on th s.

36
2.4 Hum e ral shaft fracture , transve rse , displace d (12-D/ 4.1)

1 Ca s e d e s crip t io n 2 Su rgica l a p p ro a ch

A 13-year-old m ale was stru ck by a m otor veh icle w h ile rid in g Sk in in cis io n s
h is bicycle. He su stain ed a tran sverse m idsh aft fractu re of th e Sym m etr ical m ed ial an d lateral sk in in cision s are created
hu m eru s. Th e fractu re was u n stable an d d isplaced, produ cin g startin g 1 cm above th e epicon dylar region s an d exten d in g
a visible ax ial deform ity of th e arm . approx im ately 3 cm prox im ally.

Ap p ro a ch
After spreadin g th e su bcu tan eou s tissu e an d th e fascia, place
th e awl at 90° to th e bon e at th e u pper edge of th e in cision s.
Care m u st be taken to place th e awl exactly on th e lateral
an d m edial edges of th e bon e. On th e u ln ar side, on e mu st be
aware th at th e distan ce from th e skin su rface to th e bon e is
greater becau se of th e accen tu ated u ln ar waist of th e h u m eru s.
Take care n ot to in ju re th e u ln ar n er ve. On th e radial side, it
is im portan t to always work d istally in order to avoid in ju rin g
th e rad ial n erve ( Fig 2 .4 -2 ).

1 2

a b

Preoperative AP an d lateral x-rays show in g an

Fig 2 .4 -1a – b
tran sverse, com pletely displaced hu m eral sh aft fractu re.
An atom ical location of th e n erves. It is im portan t to
Fig 2 .4 -2
rem em ber th at th ree n er ves ru n th rou gh th is area:
1 An terolateral—th e rad ial n erve
2 An terom edial—th e m edian n erve
3 Posterom ed ial—th e u ln ar n er ve

37
 2 Hu m e ru s

2 Su rgica l a p p ro a ch (co n t)

En t ra n ce s it e s a n d n a il in s e r t io n Becau se of th e sh arpn ess of th e edges of th e hu m eral cortices in

Drill th e cortical en tran ce sites, bein g carefu l th at th ey are th is area, one h as to carefu lly con trol the awl so th at it w ill not
sym m etrically placed. To en ter the m edu llary can al, th e awl m igrate eith er an terior or posterior. In troduce both n ails an d
is progressively brou gh t to an obliqu e an gle of 45° ( Fig 2 .4 -3a ). advance them proxim ally to the fractu re line ( Fig 2 .4 -3b – c).

a b c

Fig 2 .4 -3 a – c
a Th e awl is u sed to carefu lly produ ce th e en tran ce sites b Th e lateral n ail is in serted an d advan ced prox im ally in th e
w h ich sh ou ld be sym m etrically placed. On ce seated in m edu llar y can al.
th e cortical bon e, th e awl is th en m oved in a 45° an - c Th e secon d n ail is th en in serted an d both n ails are
gle, d irected to en ter th e m edu llary can al of th e d istal advan ced prox im ally to th e fractu re.
h u m eru s.

38
 2 .4 Hu m e ra l s h a ft fra ct u re , t ra n s ve rs e , d is p la ce d (12 -D/ 4 .1)

3 Re d u ct io n a n d fixa t io n

Dire ct a n d in d ire ct re d u ct io n Na il p la ce m e n t
The fractu re is reduced by h avin g the proxim al fragm en t sta- The second n ail is then advanced into the proxim al frag-
bilized by an assistan t and m an ipu latin g th e distal fragm ent, m ent ( Fig 2 .4 -4 b ). Both n ails are advanced u p to the proxim al
u sin g both n ails like h an dles. After th e fragm en t fractu re su r- m etaphyseal area. It is im portan t to en su re th at the n ails are
faces h ave been brou gh t in to con tact, th e tip of on e of th e n ails not tw isted arou n d one an oth er to avoid creatin g a corkscrew
is advanced a few centim eters into the m edu llary can al of the ph en om en on . The correct align m en t of both n ails is ach ieved
proxim al fragm en t ( Fig 2 .4 -4 a ). An indirect reduction is per- by slightly rotatin g them to place their ben din g apices directly
form ed by rotatin g th is n ail to brin g th e fractu re su rfaces into opposite each other at the level of the fractu re site. The n ail ends
better apposition . are cu t an d bu ried in th e su bcu tan eou s tissu e. Th e wou n ds are
closed w ith on e or two su tu res ( Fig 2 .4 -4 c).

a b c

Fig 2 .4 -4 a – c
a Th e fractu re is partially redu ced by m an u al m an ipu lation b Th e in d irect redu ction is com pleted by sligh tly rotatin g th e
followed by advan cem en t of th e rst n ail in to th e prox im al n ail an d advan cin g th e secon d n ail.
fragm en t. c Fin al position of th e cu t n ails in wh ich th eir ben d in g apices
are placed directly opposite each oth er at th e fractu re site.

39
 2 Hu m e ru s

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Active m otion of the extrem ity can begin im m ediately. On the can be perform ed 3 m on th s later if adequ ate con solidation an d
follow in g day ju st prior to disch arge, x-rays are taken to con- rem odelin g are dem on strated on the x-rays ( Fig 2 .4 -5 c– d ). Th e
rm m ain ten an ce of th e redu ction ( Fig 2 .4 -5 a – b ). At 4 weeks gu idelines for n ail rem oval in pathological fractu res can be
post in ju ry, if th ere is su f cien t callu s form ation on th e x-rays, fou nd in ch apter 7 Special indication s.
all activities in clu din g sports are allowed. Rem oval of th e n ails

a b c d e f

Fig 2 .4 -5 a – f
a – b Postoperative AP an d lateral x-rays dem on strate a good e –f AP an d lateral x-rays taken 1 year after su rgery; th e ch ild
fractu re redu ction . Th ere is w ide separation of th e ben d- h ad a secon d (su bcapital) hu m eral fractu re sh ow in g
in g apices at th e fractu re site. com pletely rem odelin g of th e previou s fractu re region .
c– d AP an d lateral x-rays at 3 m on th s postoperatively dem -
on strate fu ll con solidation ; n ail rem oval is plan n ed.

40
 2 .4 Hu m e ra l s h a ft fra ct u re , t ra n s ve rs e , d is p la ce d (12 -D/ 4 .1)

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Fig 2 .4 -6 a – bAsym m etr ica l en tran ce sites a n d sym m etr ic Fig 2 .4 -8 To obtain optim al a lign m en t, th e sk in in cision s
im pla n tation ca n resu lt in in su f cien t a lign m en t becau se alon g w ith th e cortical h oles mu st be exactly sym m etrical.
of th e asym m etr ical location s of th e ten sion ban ds.

a b

Fig 2 .4 -7a – b Ner ve ir r itation . It is im portan t to u se th e epicon dyles as th e referen ce

a In th e lateral approach , an terior poin ts for th e in cision s. Palpate th e latera l/ m edia l edge of
or too an ter ior in trodu ction th e hu m eru s exactly a n d dr ill w ith care.
of th e n ail ca n in ju re th e rad ial
n er ve.
b On th e m ed ial side, too an ter ior
or too poster ior in trodu ction
of th e n a il ca n in ju re th e m ed ian
a b
or u ln ar n er ve.

41
 2 Hu m e ru s

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Fig 2 .4 -9 Tw istin g on e n ail If du rin g im plan tation an d redu ction a n ail is rotated,
arou n d th e oth er (corkscrew it m u st be derotated to retu rn th e tip to its in itial position .
effect) com prom ises th e Avoid m ore th an 180° tu rn s.
bracin g fu n ction of th e n ails
an d redu ces th e elasticity of If th e n ails becom e tw isted, pu ll ou t on e n ail an d rein sert
th e m eth od. Th is resu lts in an an oth er on e.
im pairm en t of th e stability of
th e redu ction .

Fig 2 .4 -10 a – bIf a n u m ber of Th is n ail, w h ich h as lost its origin al ten sion ban d, n eeds
m an ipu lation s are n ecessar y to to be ch an ged to a n ew on e w ith th e correct m ech an ical
in trodu ce th e n ail in to th e properties.
secon d fragm en t, th e sh ape of
th e n ail m ay be visibly destroyed.
Th u s th e ten sion ban ds are
lost an d n o lon ger stabilize th e
a b
fractu re adequ ately.

Re h a b ilit a t io n Re h a b ilit a t io n
Flexion a n d exten sion of th e elbow m ay be lim ited if Carefu lly cu t th e n ails su f cien tly so th ey w ill n ot irritate
th e en ds of th e n a ils irr itate th e fascia an d th e su bcu ta n eou s th e su bcu tan eou s tissu es on ce active m otion is begu n .
tissu e. Avoid pain fu l passive m obilization prior to n ail rem oval.
Occasion ally, th e n ail en d m ay n eed to be sh orten ed to
allow th e resu m ption of free elbow m otion .

42
43
 3 Elbow

3 .1 In t ro d u ct io n —e lb o w fra ct u re s 45
1 In d ica tio n 4 5
2 Pa tie n t p re p a ra tio n a n d p o sitio n in g 4 6
3 Su rgica l p rin cip le s 4 8
4 Po sto p e ra tive ca re a n d im p la n t re m o va l 4 8

3 .2 Su p ra co n d yla r h u m e ra l fra ct u re , clo s e d ,

e xt e n s io n t yp e (13 -M/ 4 .1– IV) 5 3

3 .3 Su p ra co n d yla r h u m e ra l fra ct u re (13 -M/ 4 .1– IV) 59

3 .4 Ra d ia l n e ck fra ct u re , d is p la ce d (21-M/ 4 .1-III) 63

3 .5 Ra d ia l n e ck fra ct u re , co m p le t e ly d is lo ca t e d
(21-E/ 2 .1-III) 67

44
3.1 Introduction —e lbow fracture s

1 In d ica t io n

1.1 Su p ra co n d yla r h u m e ra l fra ct u re s Sp e cia l in d ica t io n s

Th ere are oth er con dition s in wh ich su pracon dylar fractu res
Su pracon dylar hu m eral fractu res are classi ed as 13-M/4 m ay n eed to be stabilized su rgically:
accord in g to th e AO com preh en sive classi cation for lon g- Th ose w ith exion pattern s
bon e fractu res in ch ildren (see appen dix). Open fractu res
Th ose requ irin g vascu lar repair
Th ere are fou r grades of d isplacem en t: Patien ts w ith oth er m ajor in ju ries (polytrau m a)
I u n d isplaced, n o torsion al failu re
II displacem en t u su ally in th e sagittal plan e (an tecu r va- In all cases n eed in g redu ction an d xation , ESIN is an option .
tu re or recu rvatu re), n o torsion al failu re Crossed percu tan eou s K-w ire xation follow in g closed redu c-
III addition al displacement in a secon d, u su ally the coron al tion is th e m ost practiced m eth od. However, it requ ires an
plane (antecu rvatu re or recu rvatu re an d varu s or valgu s), addition al cast an d is associated w ith th e risk of u ln ar n er ve
torsion al failu re in ju r y (in case of bilateral crossed K-w ires). Utilizin g eith er an
IV displacem en t in th ree planes or com plete displacement extern al xator or ESIN allow s early posttrau m atic m ovem en t
w ith out any fragmen t con tact, torsion al failu re w h ich m ay preven t som e posttrau m atic stiffn ess of th e elbow.
In tram edu llary xation h as th e lowest risk of a n er ve in ju r y
Tre a t m e n t b a s e d o n cla s s i ca t io n occu rrin g in traoperatively.
Th e prin cipal treatm en t m odality is u su ally based u pon th e
exact classi cation : Ad va n ta ge s
Only if p e rfe ct re d u ctio n is p o ssible , ESIN ha s th e fo l-
Grade I: orth oped ic treatm en t w ith plaster cast lo w in g a d va n ta ge s o ve r o th e r m e th o d s o f xa tio n:
Grade II: Exce lle n t sta bility, h e nce n o ca st is n e ce ssa ry.
Gradu al redu ction by th e Blou n t m eth od (cu ff an d collar) Th e in cid e nce o f cubitu s va ru s o r cubitu s va lgu s is
Active m an ipu lative redu ction an d im m obilization w ith ve ry lo w.
th e Blou n t collar an d cu ff No im pla n t cro sse s th e e lb o w jo in t.
In som e cases osteosyn th esis w ill be n ecessar y becau se
th e redu ction can n ot be adequ ately stabilized
Grades III/ IV: redu ction an d su rgical stabilization are
n ecessary u sin g th e th ree com m on su rgical tech n iqu es:
percu tan eou s pin n in g, extern al radial xator, or an tegrade
stabilization by ESIN.

45
 3 Elb o w

1 In d ica t io n (co n t)

1.2 Ra d ia l n e ck fra ct u re s Sp e cia l in d ica t io n s

In ch ildren w h o h ave su stain ed a polytrau m a, an ipsilateral
In d ica t io n s fractu re, or an in ju ry in th e extrem ity, th e ESIN tech n iqu e is
Rad ial n eck fractu res are classi ed as 21-M /1 or M /4 especially u sefu l as it elim in ates th e n eed for postoperative
(see Appen d ix). im m obilization .
Becau se of th e sm all poten tial for rem odelin g, a m ore precise
Th ere are th ree grades of d isplacem en t: an atom ical redu ction n eeds to be obtain ed w ith th e ESIN
I n o an gu lation an d n o d isplacem en t tech n iqu e in th e ch ild.
II an gu lation w ith d isplacem en t less th an h alf of th e
bon e d iam eter Ad va n t a ge s
III an gu lation w ith d isplacem en t m ore th an h alf of th e Th ere are fou r m ain advan tages of th e ESIN tech n iqu e in th e
bon e d iam eter m an agem en t of rad ial n eck fractu res:
Becau se it avoids a d irect approach to th e fractu re site,
Grade II an d III fractu re pattern s u su ally requ ire su rgical th ere is u su ally less trau m a to th e local vascu lar su pply.
in ter ven tion u sin g on e of th e follow in g two procedu res: Th is decreases th e risk of avascu lar n ecrosis of th e rad ial
percu tan eou s m an ipu lation an d pin n in g, u sin g th e ESIN h ead.
tech n iqu e or th e joystick tech n iqu e. Th is tech n iqu e avoids th e n eed for tran sarticu lar xation .
Th e stability of th e xation is excellen t w h ich allow s fu n c-
tion al postoperative m an agem en t.
Th e u se of postoperative im m obilization in th e form of a
cast is u su ally n ot n ecessar y.

2 Pa t ie n t p re p a ra t io n a n d p o s it io n in g

2 .1 Su p ra co n d yla r h u m e ra l fra ct u re s clin ic protocol. Th rom bosis proph ylax is is n ecessar y on ly in

gen eralized con dition s associated w ith an elevated risk of
Pa t ie n t p re p a ra t io n in travascu lar clottin g wh ich are seldom seen in th e ped iatric
Th ere is n o in tern ation al agreem en t as to w h eth er d isplaced age grou p. Som e of th e in d ication s wou ld be adolescen t
su pracon dylar hu m eral fractu res n eed em ergen cy in ter ven - patien ts wh o are over weigh t, th ose wh o u se tobacco produ cts
tion if th ere is n o n eu rovascu lar dam age. Often , th e ch ild’s or u se h orm on al con traceptive dru gs.
pain , th e en orm ou s swellin g of th e elbow an d th e im pressive
d isplacem en t of th e fragm en t as seen on th e x-rays w ill stim u - Pa t ie n t p o s it io n in g
late th e su rgeon to proceed w ith early operative in terven tion Th e patien t is placed in su pin e position w ith th e in ju red u pper
in th ese severely d isplaced fractu res. lim b on an arm table. Th e lateral tran slation of th e patien t
requ ires an adaptive su pport for th e h ead placed on th e side of
Me d ica t io n th e table ( Fig 3 .1-1). Th e wh ole arm in clu d in g th e sh ou lder is
An tibiotic prophylaxis is in dicated for open fractu res. Th eir su rgically prepped an d draped ( Fig 3 .1-2 ). Ster ile d rapes are
u se w ith closed fractu res sh ou ld be m an aged accord in g to th e n eeded to cover th e im age in ten si er(s).

46
 3 .1 In t ro d u ct io n —e lb o w fra ct u re s

2 Pa t ie n t p re p a ra t io n a n d p o s it io n in g (co n t)

Fig 3 .1-1 Th e patien t is placed on th e stan dard operatin g table Fig 3 .1-2 Patien t drapin g. Th e en tire u pper extrem ity is
w ith an attach ed rad iolu cen t arm table. Sin ce th e ch ild’s h ead prepped an d draped, leavin g on ly an open in g in th e stockin g-
w ill n eed to be sh ifted laterally to facilitate visu alization of n ette for th e en tran ce site in cision s.
th e en tire u pper extrem ity, a separate su pport n eeds to be
added (arrow). If available a secon d im age in ten si er m ay be
h elpfu l.

Eq u ip m e n t 2 .2 Ra d ia l n e ck fra ct u re s
In add ition to th e basic orth oped ic in stru m en ts, add ition al
specialized in stru m en ts are n eeded to stabilize th e fractu res Me d ica t io n
by th e ESIN tech n iqu e. Th ese in clu de: Th e u se of proph ylactic an tibiotics is based on th e stan dards
Stan dard ESIN set an d gu idelin es of th e clin ic protocol.
Nails:
– 1.5 –2.5 m m d iam eter, stain less steel, or titan iu m Pa t ie n t p o s it io n in g
– Th e tip m u st be sh ar pen ed to facilitate pen etration in to Th e patien t is placed in th e su pin e position w ith th e affected
th e d istal fragm en t u pper lim b on an arm table or d irectly on th e reception
K-w ires can be u sefu l as well su rface of th e in ten si er. Th is latter position produ ces better
Im age in ten si er. Norm ally, th e AP view is easily ach ieved im agin g qu ality.
w ith ou t ch an gin g th e position of th e in ten si er. If two
in ten si ers are available, th e procedu re can be perform ed After position in g, th e extrem ity is su rgically prepped an d
faster an d m ore easily becau se th e AP an d lateral view s draped free in a sterile fash ion .
can be obtain ed at th e sam e tim e. Th is avoids rotation of
th e lim b an d/or im age in ten si er.

47
 3 Elb o w

2 Pa t ie n t p re p a ra t io n a n d p o s it io n in g (co n t)

Eq u ip m e n t Nails:
In add ition to th e basic su rgical in stru m en ts, th e stan dard 1.5 –2.5 m m diam eter, stain less steel, or titan iu m ; th e
ESIN set in clu d in g both th e in stru m en ts an d n ails m u st be selected n ail sh ou ld be 33% (1/ 3) of th e d iam eter of th e
available. in tram edu llary can al.
On ly on e im age in ten si er (C-arm) is n ecessar y. Sh ar pen in g of th e tip of th e n ail is option al.

3 Su rgica l p rin cip le s

3 .1 Su p ra co n d yla r h u m e ra l fra ct u re s follow in g an open redu ction . On e advan tage of th e u se of an

extern al xator is th at by u sin g th e Sch an z screw s as joysticks
Su rgica l a p p ro a ch e s to m an ipu late th e fragm en ts, a closed redu ction m ay be facil-
If a closed redu ction can n ot be accom plish ed, th en an open itated. Th e ESIN tech n iqu e of approach in g th e fractu re in an
redu ction w ill be n ecessar y. Th ere is n o agreem en t as to an tegrade m an n er can ach ieve a perfect an d stable xation as
th e best su rgical approach . Som e su rgeon s prefer to u se a th e ideal closed redu ction . If th e fractu re site m u st be open ed
posterior in cision , splittin g th e triceps m u scle to expose th e to ach ieve a satisfactory redu ction , it is ver y easy to pu sh th e
posterior aspect of th e hu m eru s an d th e fractu re site. Oth ers n ails in to both con dyles by direct visu alization . Th ere is n o
prefer to u se a lateral an d/or m edial approach depen din g on eviden ce th at an y m eth od of stabilization h as an y advan tages
w h ere th e su spected in ter posed tissu e lies. Becau se th e soft- over th e oth er follow in g an open redu ction .
tissu e dam age by th e in itial trau m a is greatest an terior to th e
fractu re, an an terior approach is preferred by m an y even in Dire ct io n o f n a ilin g
cases w ith ou t vascu lar problem s. Th is approach preven ts add i- Th e n ails are in serted in an tegrade tech n iqu e from a su bdel-
tion al soft-tissu e trau m a to th e in tact tissu e posteriorly. toid lateral in cision u sin g two d ifferen t en tran ce sites.

Me t h o d s o f s t a b iliza t io n 3 .2 Ra d ia l n e ck fra ct u re s
In depen den t of th e su rgical approach ch osen , th e m eth od of
stabilization u su ally does n ot depen d on th e m an n er in wh ich Th e stan dard retrograde approach startin g distally in th e
th e fractu re is redu ced. K-w ires can be u sed w ith eith er an rad iu s as described in case 4.3 Forearm sh aft fractu res, tran s-
open or closed redu ction . An extern al xator is easy to place verse, is u sed.

4 Po s t o p e ra t ive ca re a n d im p la n t re m o va l

4 .1 Su p ra co n d yla r h u m e ra l fra ct u re s Ou t p a t ie n t fo llo w -u p

A follow-u p x-ray 4 –5 weeks after th e in itial su rger y u su ally
Postoperative x-ray in spection sh ou ld be don e in th e operatin g con rm es su f cien t callu s form ation . At th is poin t, m ore
room . No add ition al im m obilization is n ecessary. Som etim es active m obilization in clu d in g sports activities can be perm it-
a slin g is preferred for a few days for th e safety of an an x iou s ted. By 2 to 3 m on th s postoperatively, th ere sh ou ld be fu ll
ch ild. Movem en t is en cou raged im m ed iately, depen d in g on con solidation an d rem odelin g visible on th e x-rays prior to
th e patien t’s level of com fort. Motion in clu des elbow ex ion im plan t rem oval.
an d exten sion in add ition to pron ation an d su pin ation of
th e forearm . Ph ysioth erapy sh ou ld be avoided du rin g th is
ph ase. Th e patien t is u su ally disch arged from th e h ospital
24 –48 h ou rs postoperatively.
48
 3 .1 In t ro d u ct io n —e lb o w fra ct u re s

4 Po s t o p e ra t ive ca re a n d im p la n t re m o va l (co n t)

Im p la n t re m o va l Re h a b ilit a t io n
Th e im plan ts are u su ally rem oved as an ou tpatien t procedu re. No special reh abilitation is requ ired. Physioth erapy m ay be
Th e stan dard ESIN set or at-n osed pliers are n ecessar y to u sed in case of stiffn ess of th e elbow. Th e m obility th at is
rem ove th e two n ails. en cou raged du rin g th e rst weeks is lim ited to pron ation an d
su pin ation of th e forearm . 3 weeks later, ex ion an d exten -
4 .2 Ra d ia l n e ck fra ct u re s sion of th e elbow are allowed in order to obtain a fu ll ran ge of
m otion .
Th e rst postoperative x-ray is obtain ed wh ile still in th e oper-
atin g room . Postoperative add ition al im m obilization is u su - Im p la n t re m o va l
ally n ot n ecessar y becau se of th e stability ach ieved by th is Th e extractin g pliers from th e stan dard ESIN set, or, altern a-
tech n iqu e. Fu ll early m obility is en cou raged. A slin g m ay tively, at-n osed pliers can be u sed to extract th e n ails.
be u sed for com fort an d su bjective safety. Th e patien t is d is-
ch arged 24 –48 h ou rs postoperatively. Th e rst ou tpatien t
x-ray is obtain ed 4 –5 weeks after disch arge.

Su p ra co n d yla r h u m e ra l fra ct u re s

Pit fa lls – Pe a rls +

Ap p ro a ch Ap p ro a ch
Som etim es it is d if cu lt to m ake th e h oles w ith th e aw l in On e option is to u se a drill to m ake th e en tran ce sites.
th e stron g lateral cortex ju st below th e deltoid m u scle It is im portan t to d rill th e sites separately so th at on e is
in sertion . m ore proxim al th an th e oth er.

In ju ry to th e radial n erve is possible if th e d rill slips at th e Th e h u m eral d iaph ysis sh ou ld be h eld rm ly between
posterior aspect of th e hu m eral sh aft. th e su rgeon ’s thu m b an d in dex n ger wh en d rillin g
th e h oles. Du rin g th e d rillin g process th e aw l is d irected
from posterolateral toward an terom ed ial.

Th e rst n ail m ay be d if cu lt to advan ce in th e in tram ed- Th e ben t tip of th e n ail m ay n eed to be straigh ten ed.
u llary can al becau se of th e preben t tip.

It m ay be d if cu lt to in trodu ce an d advan ce th e secon d

n ail an tegrade easily.

Th e n ails can n ot be advan ced in to th e m ed ial or lateral Th e rst n ail, wh ich is in serted in to th e prox im al
h u m eral colu m n s. en tran ce site, m u st be orien ted toward th e lateral h u m er-
al colu m n Th e secon d n ail m u st be advan ced by altern at-
in g clockw ise an d cou n terclockw ise rotator y m ovem en ts
so th at it does n ot tw ist arou n d th e rst n ail. As it
approach es th e su pracon dylar area, it mu st be rotated
180° to d irect it toward th e m ed ial h u m eral colu m n .
49
 3 Elb o w

Su p ra co n d yla r h u m e ra l fra ct u re s (co n t)

Pit fa lls – (co n t) Pe a rls + (co n t)

Re d u ctio n a n d xa t io n Re d u ct io n a n d xa t io n
Th e fractu re can n ot be redu ced by a application of th e Th e brach ial mu scle m ay occasion ally becom e en trapped
u su al extern al m an ipu lative m an eu vers. at th e fractu re site. In th is rare occasion , an open redu c-
tion w ill be requ ired.

Th e redu ction of th e fractu re is n ot perfect. Usu ally, th e d istal fragm en t is rotated in a m ed ial d irec-
tion . If th is is th e case, th e prox im al fragm en t, w ith
th e n ails lyin g in its in tram edu llary can al, m u st likew ise
be rotated in a m edial d irection .

Varu s or a valgu s align m en t is observed. With th is tech n iqu e, th e align m en t of Bau m an n ’s an gle
in th e d istal fragm en t is easily visu alized on th e AP x-ray,
as th e elbow is n ot in h yper ex ion .

Fig 3 -1.3 a – bWh en a n ail is advan ced distally in to th e As th e n ails are advan ced in to th e d istal hu m eral m e-
con dyle, it pen etrates th e cortex of th e d istal fragm en t. taph ysis, th e d irection of th eir tips m u st be very carefu lly
Th e in tram edu llar y n ails do n ot t correctly in th e distal m on itored on both th e AP an d lateral x-ray im ages. At
fragm en t bu t brake ou t dorsally, lead in g to a exion th is poin t, th e fractu re m u st be perfectly redu ced an d
failu re an d m ak in g revision n ecessary. stabilized by th e su rgeon so th at th e n ail can be advan ced
w ith a h am m er.

a b

Th e d istal fragm en t d isplaces as th e n ails are advan ced. Sh ar p tips are essen tial to preven t distal fragm en t
d isplacem en t. Reciprocal pressu re on th e olecran on or
h yper exion of th e elbow can also be h elpfu l.

Re h a b ilit a t io n Re h a b ilit a tio n

Stiffn ess of th e elbow. Physioth erapy is option al bu t sh ou ld n ot be in itiated
u n til at least 3 m on th s after th e in itial trau m a. If it is
started du rin g th e acu te ph ase, h eterotopic ossi cation
m ay be in du ced. Self-con trolled spon tan eou s active
m obilization by th e patien t alon e w ill preven t m ost of
th e poten tial stiffn ess.

50
 3 .1 In t ro d u ct io n —e lb o w fra ct u re s

Ra d ia l n e ck fra ct u re s

Pit fa lls – Pe a rls +

Ap p ro a ch Ap p ro a ch
Th e sen sor y bran ch of th e rad ial n erve can be in ju red Th e risk of in ju ry can be lessen ed by th e u se of a tran s-
w h en m ak in g th e en tran ce site in th e d istal rad iu s. verse sk in in cision wh ich is placed an terior to th e lateral
edge of th e d istal radial m etaph ysis. In add ition , th e u se
of a tou rn iqu et an d a larger su rgical approach w ith
d issection of th e n erve m ay be h elpfu l.

Th e rad ial artery can be in ju red at th e w rist. Th ese problem s can alm ost be elim in ated by u sin g a d rill
or a squ are-tipped aw l to create th e en tran ce site in to
th e cortex in a posterom ed ial d irection . Th e d istal rad iu s
n eeds to be h eld rm ly between th e su rgeon ’s th u m b
an d in dex n ger.

Th e n ail m ay be d if cu lt to advan ce in to th e m edu llary Th e tip of th e n ail is con tou red en ou gh to be advan ced
can al of th e radiu s. in to th e m edu llar y can al. It is im portan t th at th e tip is
n ot con tou red too m u ch . Th is can cau se an obstru ction
w ith in th e rad iu s.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Fig 3 .1-4 A satisfactory redu ction is n ot ach ieved w ith th e Fig 3 .1-5 Redu ce th e h ead par-
n ail u sin g th e joystick tech n iqu e. tially by rotatin g th e n ail.
Th en , rem ove th e sam e n ail from
th e proxim al epiph ysis, rotate
18 0 °
it 180°, an d advan ce it again in to
th e epiph ysis. Th is n ew rotation
m an eu ver sh ou ld lead to th e n al
redu ction of th e fractu re.

51
 3 Elb o w

Ra d ia l n e ck fra ct u re s (co n t)

Pit fa lls – (co n t) Pe a rls + (co n t)

Re d u ctio n a n d xa t io n (co n t) Re d u ct io n a n d xa t io n (co n t)

Th e radial h ead m ay be very th in , m ak in g it dif cu lt to Fig 3 .1-7a – e Altern atively a K-w ire can be u sed per-
stabilize w ith th e n ail tip. cu tan eou sly as a joystick to force th e h ead in to a
satisfactory position . To avoid in ju r y to th e radial n er ve,
th is K-w ire is in trodu ced th rou gh th e lateral part of
th e prox im al forearm in fu ll pron ation . Th u s, th e rad ial
n erve is sh ifted in an an terior d irection an d away
from th e K-w ire.
c

a b

e
a b c d e

Open redu ction . If closed h as n ot been ach ieved by

d an y of th e previou s tech n iqu es, an open redu ction m u st
be perform ed u sin g a posterolateral approach . Often
Fig 3 .1-6 a – eFor stabilization of a ver y sm all rad ial h ead on ly a sm all ap of periosteu m is attach ed at th e rad ial
fragm en t, especially in you n ger ch ildren , th e physis m u st h ead. If it is destroyed th e risk of avascu lar n ecrosis is
be pen etrated. relevan t. Th erefore redu ction w ith ou t an in cision of th e
a In ju ry x-ray w ith com plete displaced radial h ead. articu lar capsu le (open , bu t tran scapsu lar m an ipu lation)
b – c Situ ation after closed redu ction w ith “joystick” tech - m ay be an option to save th e periosteal blood su pply.
n iqu e.
d – e Healin g w ith ou t sign of n ecrosis after 2 m on th s. In you n g patien ts, w ith a ver y sm all rad ial h ead, a plaster
cast m u st be worn for 3 –4 weeks.

Re h a b ilit a t io n Re h a b ilit a tio n

Stiffn ess of th e elbow is rare. Gen tle active ph ysioth erapy again st resistan ce can be
ordered.

52
3.2 Supracond ylar hum e ral fracture , close d,
e xte nsion type (13 -M/ 4.1-IV)
1 Ca s e d e s crip t io n

A 5-year-old girl ju m ped from a clim bin g fram e an d fell, u sin g h er righ t
u pper extrem ity w ith th e elbow exten ded to break h er fall. Sh e presen ted to
th e h ospital w ith visible d isplacem en t an d sign i can t swellin g in th e su pra-
con dylar area. Her n eu rovascu lar fu n ction was n orm al. Th e x-rays sh owed a
fu lly d isplaced d istal hu m eral fractu re ( Fig 3 .2-1). Sh e was tran sferred im m e-
d iately to th e operatin g room becau se of th e m arked d isplacem en t of th e
fractu re fragm en ts. Th is was don e even th ou gh em ergen cy in terven tion is
u su ally on ly n ecessar y in th ose cases w ith a pu lseless wh ite forearm an d
h an d.

Preoperative x-rays. AP an d lateral view s dem on stratin g a type

Fig 3 .2 -1a – b
a b
IV posterolateral su pracon dylar fractu re pattern of th e righ t d istal hu m eru s.

2 Su rgica l a p p ro a ch

An in itial redu ction of th e fractu re sh ou ld always be perform ed prior to th e

sterile drapin g of th e extrem ity. With gen eral an d add ition al plexu s an esth e-
sia, a prelim in ar y redu ction is obtain ed. In itially, gen tle ax ial traction is
applied alon g th e ax is of th e forearm w ith cou n tertraction at th e h u m eru s.
On ce th e len gth h as been reestablish ed, th e elbow is exed as th e th u m b of
th e su rgeon sim u ltan eou sly pu sh es for ward on th e olecran on .

C-a rm co n t ro l
Control the qu ality of the reduction in th e coron al plan e u sin g th e AP im age
Fig 3 .2 -2 Th e sk in in cision (arrow) for th e
inten si er views. A Bau m an n‘s an gle between 70° an d 80° mu st be ach ieved.
en tr y poin ts is m ade on th e lateral aspect of
Con trol th e qu ality of th e redu ction in th e sagittal plan e w ith th e lateral C-arm
th e m iddle th ird of th e arm ju st below th e
con trol views. The an gle of the sh aft to the condyles of the hu m eral distal
h u m eral in sertion of th e deltoid m u scle (dot-
epiphysis (sh aft–condylar an gle) n eeds to be reduced to between 30° an d 40°.
ted lin e).
Sk in in cis io n
Th e sk in is in cised for a distan ce of 4 cm on th e lateral side of th e arm from
th e m idth ird prox im ally to ju st below th e d istal in sertion of th e deltoid m u s-
cle ( Fig 3 .2-2 ).

53
 3 Elb o w

2 Su rgica l a p p ro a ch (co n t)

Ap p ro a ch Na il a d va n ce m e n t
The su bcutaneou s tissue is dissected u n til the lateral cortex of The two n ails are not precontou red, but their tips are ben t and
the hu m eru s is reached. The periosteu m is incised. The lateral sh arpen ed. As th ey are in trodu ced an d advan ced an tegrade
cortex is perforated w ith an awl. In itially, it is drilled at righ t in to th e diaphysis, th e tips are directed towards th e lateral
an gles to preven t th e tip from slippin g. Once the cortex h as cortex ( Fig 3 .2-4 ).
been pen etrated, the awl h andle is an gled 45° to th e sh aft axis
to produce an oblique can al. Th is facilitates the in troduction of
the n ails into the m edu llary can al ( Fig 3 .2-3 ). Two sites are
requ ired w ith one bein g m ore proxim al an d the second sligh tly
m ore an terior and distal th an the other.

a b a b

Th e location of th e en tran ce sites on th e

Fig 3 .2 -3 a – b Fig 3 .2 -4 a – bDistal advan cem en t. Th e n ails are advan ced
proxim al hu m eru s. an tegrade to th e fractu re. At th is poin t th e tips of both n ails
a Lateral view. are poin tin g laterally.
b AP view. a Lateral view.
b AP view.

54
 3 .2 Su p ra co n d yla r h u m e ra l fra ct u re , clo s e d , e xt e n s io n t yp e (13 -M/ 4 .1-IV)

2 Su rgica l a p p ro a ch (co n t) 3 Re d u ct io n a n d fixa t io n

When the tips are bein g advanced into the metaphysis, the more Re d u ct io n
distally im planted n ail is rotated 180° toward the m edial The fractu re is again reduced as previou sly described u nder the
colu m n ( Fig 3.2-5 ). Th is needs to be accom plished carefu lly to control of a C-arm . The elbow m ay be exed to 60° to obtain a
preven t one n ail from tw istin g totally arou nd the other n ail. better AP view as lon g as th e redu ction is perfect on th e lateral
The tip of the most proxim ally in serted n ail rem ain s directed view ( Fig 3 .2-6 ).
laterally. In the lateral view, the tips of both n ails are tu rned
slightly so th at they are poin tin g directly toward the metaphy-
sis.

18 0 ° 18 0 °

a b a b

Fig 3 .2 -5 a – bNail rotation . As th e n ails are en terin g th e Fig 3 .2 -6 a – b Redu ction an d stabilization . Th e fractu re frag-
m etaph ysis, th e tip of th e m ost distally in serted n ail is rotated m en ts are stabilized w ith exion of th e elbow. On ce redu ced,
180° so th at it advan ces in to th e m ed ial colu m n (arrow). th e tips of th e n ails are th en carefu lly advan ced in to th e d istal
a Lateral view. fragm en t.
b AP view. a Lateral view.
b AP view.

55
 3 Elb o w

3 Re d u ct io n a n d fixa t io n (co n t)

St a b iliza t io n
The reduction is m aintain ed by the su rgeon wh ile an assistan t u n der th e C-arm ( Fig 3 .2-7 ). If both im plan ts are reliably intro-
advan ces th e n ails on e at a tim e by gen tle h am m er blows as duced in to the distal fragment, the n ails can be im pacted in to
far as a few m illim eters proxim al to th e fractu re lin e. Rotation the distal m etaphyseal bone ( Fig. 3 .2-8 ). The proxim al part of
of th e n ails mu st be strictly avoided du rin g th is m an eu ver. each n ails is cu t so th at it lies u nder the skin . Closu re of th e skin
Progression of the n ails in to th e distal hu m eru s is controlled is accom plished in the standard m an ner.

a
a b

Fig 3 .2 -7a – b Fin al n ail in sertion . Th e proxim al en ds of th e Fig 3 .2 -8 a – bAP an d lateral postoperative x-rays dem on -
n ails are cu t an d in serted to be u sh w ith th e cortex. Th e in ci- stratin g th e an atom ical redu ction an d xation w ith th e tips
sion s are closed. im pacted in th e m etaph ysis. On th e AP view, th e Bau m an n ’s
a Lateral view. an gle is n orm al. On th e lateral view, th e sh aft–con dylar
b AP view. an gle h as been restored. Th is provides su f cien t stabilization
to perm it fu ll postoperative m obilization .

56
 3 .2 Su p ra co n d yla r h u m e ra l fra ct u re , clo s e d , e xt e n s io n t yp e (13 -M/ 4 .1-IV)

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Th e u se of a slin g to am eliorate pain at th e u pper extrem ity is Nails are u su ally rem oved after 2 m on th s, depen din g on th e
option al for a few days. A cast is n ot n ecessar y. Ph ysio- con solidation of th e bon e ( Fig 3 .2-9 ). On e m on th later, th e
th erapy is n ot recom m en ded. Movem en t of th e arm is n ot patien t was fu lly active w ith ou t an y fu n ction al restriction s.
lim ited except by pain .

Fu ll recover y. AP an d lateral x-rays taken after

Fig 3 .2 -9 a – b
n ail rem oval. A com plete an atom ical an d fu n ction al recovery
a b
h as been ach ieved.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
If th e en tran ce can als are per pen d icu lar to th e bon e ax is, Obliqu ity of th e h oles toward th e elbow m akes th e
it is d if cu lt to in trodu ce th e n ails. progression of th e n ails easier.

Th e tip of on e n ail can n ot be placed in th e aim ed con dylar Som etim e it is h elpfu l to “ch an ge th e side”: Th e proxim al
colu m n . n ail m ay m ore easily be placed in th e m edial colu m n
an d th e distal n ail in th e lateral colu m n .

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Becau se of friction it m ay be dif cu lt to advan ce th e As th e secon d n ail is advan ced, care m u st be taken to
secon d n ail d istally. Rotation of th e n ail m ay be n ecessary avoid tw istin g it arou n d th e rst n ail w h ich can create a
to advan ce it. corkscrew ph en om en on . Th e n ail n eeds to be rotated
altern ately clockw ise an d cou n terclockw ise rath er th an
m akin g a com plete rotation .

57
 3 Elb o w

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Re d u ct io n a n d xa t io n (co n t) Re d u ct io n a n d xa t io n (co n t)
Th e n ails m ay pen etrate th e cortex of th e d istal m etaph y- Rotation m an eu vers are n ot carried ou t wh en crossin g
sis an d en d u p in th e join t cavity. th e fractu re lin e. With d raw th e n ails prox im ally a few
m illim eters to again or ien t th e tips exactly an d th en
advan ce th e n ails again in a d istal d irection .

70 °– 8 0 °

a b

It is im portan t th at th e Bau m an n ‘s an gle

Fig 3 .2-10 a – b
on th e AP view m easu res between 70° an d 80°.

58
3.3 Supracond ylar hum e ral fracture (13 -M/ 4.1– IV)

1 Ca s e d e s crip t io n

A 10-year-old boy su stain ed an in ju ry to h is left u pper

extrem ity wh ile doin g a judo m an eu ver. He presen ted to th e
em ergency room w ith a deform ed an d swollen left elbow.
A clin ical exam in ation revealed an absen t radial pu lse w ith
absen t fu n ction of both th e radial n erve an d th e an terior in ter-
osseou s bran ch of th e m edian n erve. Th e in itial x-rays revealed
a type IV su pracon dylar exten sion fractu re pattern w ith pos-
terolateral displacem en t of the distal fragm en t ( Fig 3.3 -1).
X-rays of th e left elbow taken on arrival at th e
Fig 3 .3 -1a – b
em ergen cy room . A type IV exten sion fractu re pattern w ith a
a b
posterolaterally displaced distal fragm en t.

2 Su rgica l a p p ro a ch

Th e su rgical approach th at is requ ired for th is case h as been Th e m ost im portan t aspect in th e m an agem en t of th is patien t
described in detail in ch apter 3.2 Su pracon dylar h u m eral is th e retu rn of th e radial pu lse after prelim in ary redu ction .
fractu re, closed, exten sion type.

3 Re d u ct io n a n d fixa t io n

Ph ys e a l p e n e t ra t io n
Nails of 2.0 m m or K-w ires of 1.8 m m d iam eter are best for
th is type of fractu re. Th e redu ction an d xation were per-
form ed exactly as described in th e previou s case.
Becau se th e distal fragm en t is very sm all, th e radial n ail w ill
need to perforate the physis of th e lateral condyle in th is case.
The tip mu st be secu red deep in side the capitu lu m ( Fig 3.3 -2 ).
Ex perien ce in m an y prior cases h as sh ow n th at th ere are n o
grow th con sequ en ces from pen etration of th e ph yses w ith th e
sm ooth n ails. It m u st be em ph asized at th is poin t th at m u lti-
ple perforation s of th e ph ysis or vigorou s rotation of th e n ail
a b
tip du rin g th e advan cem en t process m u st be avoided.
Postredu ction x-rays. AP an d lateral x-rays follow in g stabilization u sin g th e ESIN an tegrade
Fig 3 .3 -2 a – b
tech n iqu e. Becau se th e d istal fragm en t was so sm all, th e tip of th e lateral n ail was rotated an teriorly to
pen etrate th e ph ysis to provide m ore stable seatin g in th e epiphysis of th e lateral con dyle (arrow).

59
 3 Elb o w

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Ea rly m o t io n Fo llo w -u p a n d im p la n t re m o va l
The u se of a cast or slin g is not recom m ended. The stability of X-rays obtained 3 mon th s postoperatively demon strated a
the n ails w ith in the capitu lu m allows early m obilization and norm al an atom ical align ment w ith good xation . On the
in ten sive physioth erapy for reh abilitation . With th is patien t, AP view the Bau m an n‘s an gle is 80°. On the lateral view, the
physiotherapy was prescribed for reh abilitation of the radial sh aft–condylar an gle is 30°. Fractu re h ealin g was com plete,
an d in terosseou s n erve palsies. Both n erves dem on strated fu ll thu s perm itting n ail removal ( Fig 3.3 -3 ).
recovery w ith in 2 weeks.

2 weeks postoperatively, the patient h ad exion to 100° and

exten sion to 70°. By 6 weeks, elbow exion h ad increased to
130° w ith exten sion progressin g to 30°.

30°
80°

Fig. 3 .3 -3 a – bAP an d lateral x-rays taken follow in g n ail

rem oval dem on strate an atom ical align m en t of th e d istal frag-
m en t alon g w ith com plete h ealin g of th e fractu re. Th ere seem s
to be n o grow th d istu rban ce of th e lateral con dylar ph ysis du e
a b
to th e pen etration of th e n ail.

60
 3 .3 Su p ra co n d yla r h u m e ra l fra ct u re (13 -M/ 4 .1– IV)

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Even th ou gh th e radial pu lse is restored, th e fractu re Open redu ction is n ecessar y. On e of th e stan dard su rgical
can n ot be redu ced by m an ipu lative m eth ods alon e. Th is approach es (posterior, an terior, m ed ial, or lateral) is
is u su ally th e resu lt of m u scle in ter position or becau se u sed accordin g to th e type of fractu re an d th e su rgeon ‘s
th e tip of a fragm en t is bu tton h oled in to th e su rrou n din g preferen ce Open redu ction is n ot a con tradiction to th e
soft tissu es. u se of ESIN. Follow in g an open redu ction , th ere is a
h igh er in ciden ce of scarrin g of th e join t capsu le an d oth er
soft-tissu e stru ctu res at th e elbow. Th e possibility of
im m ed iate postoperative m obilization m akes th e ESIN
m eth od especially attractive.

Th e fractu re lin e is ver y d istal. Th is m akes it d if cu lt Position in g of both n ail tips an teriorly allow s th em to be
to obtain su f cien t xation w ith in th e sm all d istal advan ced m ore distally. Th is resu lts in a m ore stable
m etaph ysis. xation . Th e ph ysis can be pen etrated by th e sm ooth tip
of th e n ail w ith little risk of grow th arrest (see Fig 3 .3 -3 ).

61
 3 Elb o w

62
3.4 Radial ne ck fracture , displace d (21-M/ 4.1-III)

1 Ca s e d e s crip t io n

Follow in g a fall on h is ou tstretch ed u pper extrem ity, th is

9-year-old boy presen ted to th e h ospital w ith pain an d swell-
in g localized in th e left prox im al forearm . X-rays revealed a
d isplaced rad ial n eck fractu re.

After adequ ate relaxation was ach ieved w ith gen eral an esth e-
sia, an attem pt to redu ce th e fractu re by con ser vative m an -
agem en t was rst m ade by applyin g gen tle axial traction on
th e forearm . Follow in g th is, th e su rgeon applied pressu re
d irectly over th e rad ial h ead w ith th e elbow exed. At th e
sam e tim e, th e forearm was forced in to fu ll pron ation . Im ages
a b obtain ed on th e C-arm follow in g th is con ser vative procedu re,
revealed an in com plete redu ction ( Fig 3 .4 -1).
Prim ary redu ction . AP an d lateral x-rays of th e
Fig 3 .4 -1a – b
left elbow follow in g an attem pt at con ser vative m an agem en t It is a lwa ys im p o rta n t th a t a tte m p ts a t clo se d re du ctio n
reveal an u n satisfactory align m en t of th e rad ial h ead in a re p e rfo rm e d p rio r to su rgica lly p re p p in g a n d d ra p in g
relation to th e prox im al sh aft. o f th e in ju re d e xtre m it y.

2 Su rgica l a p p ro a ch

Sk in in cis io n
A 2 cm lon g sk in in cision is m ade at th e lateral aspect of th e d istal forearm ju st
prox im al to th e d istal ph ysis of th e rad iu s ( Fig 3 .4 -2 ). It is very im portan t th at th e
in cision is palm ar to th e su per cial bran ch of th e rad ial n erve an d th e su per cial
rad ial vein . An altern ative approach is to m ake th e in cision dorsally to create th e
en tran ce site in th e dorsal cortex th rou gh th e palpable dorsal tu bercle of rad iu s as
described in case 4.3 Forearm sh aft fractu re, tran sverse (see Fig 4 .3 -3 ).

Ap p ro a ch
The su bcutaneou s tissue is dissected to th e lateral cortex of the radiu s. The periosteu m
is incised. Next, th e lateral cortex is perforated to create the en trance site w ith either
Fig 3 .4 -2 Th e sk in in cision (arrow) is the squ are tipped awl or u sin g a 3 –3.5 m m drill. It is im portan t th at th e drill is per-
located prox im al to th e rad ial styloid pen dicu lar to th e cortex u n til it is well seated in th e bon e. Th is preven ts th e drill from
(obliqu e lin e). It m u st also lie an terior to slippin g off the cortex. On ly a sin gle en trance site is n eeded.
th e su per cial radial n erve (dotted
lin e).

63
 3 Elb o w

2 Su rgica l a p p ro a ch (co n t) 3 Re d u ct io n a n d fixa t io n

Ad va n ce m e n t o f t h e n a ils Re d u ct io n
The n ail is introduced th rou gh the en trance site and is advanced Under C-arm con trol an indirect reduction of the radial head is
retrograde in to th e radial diaphysis ( Fig 3 .4 -3 a ). It m ay be neces- ach ieved by th e su rgeon u sin g th e thu m b to apply direct pres-
sary to rotate th e tip once or tw ice. Th e su rgeon also needs to su re over the head fragm en t ( Fig 3 .4 -4 a ). Then , the assistan t
u nderstand th at when the sh arp tip of the n ail reaches the su rgeon u ses the h am m er to gently advance the n ail tip in to the
radial head, it needs to be positioned w ith the tip in th e plane head. Rotation of the n ail mu st be strictly avoided du rin g th is
of th e m axim al h ead displacem en t ( Fig 3 .4 -3b ). m aneu ver in order n ot to avoid creatin g a cavity in th e cen ter
of th e m etaphysis. At th is poin t, th e radial h ead is secu red by
the n ail tip. The n al reduction can be ach ieved by gently rotat-
in g th e n ail w ith th e T-h an dle as th e forearm is rotated in to
pron ation ( Fig 3 .4 -4 b ). Du rin g th is process, direct pressu re is

18 0 °

a b a b

Fig 3.4 -3a – b Fig 3 .4 -4 a – b

a Diaphyseal in sertion . a In d irect redu ction .
After passin g th rou gh the distal m etaphyseal entran ce site, On ce th e tip is directed toward th e cen ter of th e h ead,
the n ail is advanced retrograde in to the diaphysis. d irect m anu al pressu re is applied to th e h ead fragm en t to
b Rad ial h ead en tran ce. ach ieve partial redu ction .
Wh en th e n ail tip ex its th e n eck, th e tip is d irected to th e b Nail rotation .
rad ial h ead. Wh en th e tip is secu red w ith in th e h ead fragm en t, th e
n al redu ction is ach ieved by rotatin g th e n ail (arrow).

64
 3 .4 Ra d ia l n e ck fra ct u re , d is p la ce d (21-M/ 4 .1-III)

3 Re d u ct io n a n d fixa t io n (co n t)

applied to the lateral part of the radial head. Reduction mu st be

carried ou t at all tim es u n der C-arm con trol.

Fin a l s e a t in g
Once the su rgeon is satis ed w ith the n al reduction , the n ail
is secu red by im pactin g the tip to penetrate th e physis of th e
radial head. Th is places the tip ju st w ith in the su bch ondral
bon e of th e epiphysis ( Fig 3 .4 -5 ). After n al seatin g h as been
ach ieved, th e distal part of the n ail is ben t 90° and cut so th at
th e tip lies deep below the skin ( Fig 3 .4 -6 ).

a b

Postoperative x-rays. Th e proxim al en d of th e

Fig 3 .4 -6 a – b
n ail h as been cu t; th e tip on ly ju st pen etrates th e ph ysis.

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Early fu n ction al recover y.

Th e on ly situ ation in wh ich a cast is felt to be n ecessary is in

th e very you n g ch ild w ith a th in epiph ysis. Even th en , it is n ot
in d icated for m ore th an 3 weeks. As soon as postoperative
pain perm its, early active m otion is en cou raged.

Th e n ails can n ot be rem oved less th an 8 weeks after su rger y.

Fig 3 .4 -5 Fin al position .

Th e n ail is in its n al position w ith th e
h ead well align ed an d redu ced. Th e tip
is xed deep in th e epiph ysis.

65
 3 Elb o w

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Dam age of th e su per cial bran ch of th e rad ial n erve or Wh en creatin g th e en tran ce site in th e cortex, take
th e rad ial artery. care to avoid in ju r y to th e rad ial arter y en su rin g th at
th e aw l or d rill does n ot slip in an an terior d irection .
Cran ial obliqu ity of th e en tran ce can als w ill greatly
facilitate th e retrograde advan cem en t of th e n ails.
En try poin t th rou gh Lister’s tu bercle.

Re d u ctio n a n d xa t io n Re d u ct io n a n d xa t io n
Th e n ail is advan ced by gen tle h am m er blow s u n til it If th e redu ction of th e rad ial h ead is in com plete, it is
rests secu rely in th e rad ial h ead. In th is part of th e often h elpfu l to rem ove th e n ail from th e epiph ysis. It
stabilization process, rotation of th e n ail m u st be avoided is th en reor ien ted toward th e lateral part of th e h ead.
as th e tip w ill destroy th e can cellou s bon e of th e h ead. Rotation of th e n ail to redu ce th e h ead in to correct
Th is in tu rn can create a cavity w h ich w ill n ot provide align m en t is repeated.
adequ ate xation .

To obtain th e n al redu ction , th e rotation of th e n ail

m u st be gen tle an d perform ed in con ju n ction w ith th e
pron ation of th e forearm .
a b c d e f

g h i j k l

Th e series of x-rays illu strates th e redu ction

Fig 3 .4 -7a – l
an d xation of th e radial h ead in a descriptive way.

66
3.5 Radial ne ck fracture , com ple te ly dislocate d (21-E/ 2.1-III)

1 Ca s e d e s crip t io n

An 8-year-old girl u sed h er righ t ou t- n atu re of h er in ju ry. He determ in ed th at th e rad ial h ead was
stretch ed arm to break h er fall. com pletely d islocated. Th e tru e n atu re of th is fractu re was
Sh e presen ted w ith pain an d swell- d if cu lt to appreciate becau se th e d isplacem en t of th e rad ial
in g in th e righ t elbow area. Th e in ju r y h ead was com plete, lyin g proxim ally in th e adjacen t soft tis-
x-rays ( Fig 3 .5 -1) were in ter preted as su es at 90° to th e rad ial n eck ( Fig 3 .5 -2 ). A m ore carefu l evalu -
bein g n orm al. Becau se of failu re to ation of th e im age dem on strates th at th e h ead
prom ptly resolve h er sym ptom s, sh e appeared like a d isk on th e AP im age an d th e n eck was su b-
was seen in an oth er facility by a sec- lu xated posterolaterally in relation sh ip to th e capitu lu m .
on d su rgeon w h o recogn ized th e tru e

a b a b

Fig 3 .5 -1a – b In ju ry x-rays. Th ese AP an d lateral x-rays taken Fig 3 .5 -2 a – bA closer look. On th e AP view, th e rad ial h ead
at th e rst h ospital were in ter preted as bein g n orm al. h as a d isc-like appearan ce (arrow). Th e radial h ead is seen to
be rotated by 90° to th e proxim al radiu s (arrow) on th e lateral
view. On both im ages, th e proxim al rad iu s is n ot align ed w ith
th e cen ter of th e lateral con dylar ossi cation (dotted lin e).

2 Su rgica l a p p ro a ch

In itially, a n elastic n ail was in trodu ced in to th e radiu s u sin g

th e d istal lateral m etaph yseal en tran ce poin t as descr ibed in
ch apter 3.1 In trodu ction —elbow fractu res.

67
 3 Elb o w

3 Re d u ct io n a n d fixa t io n

In it ia l t re a t m e n t Op e n re d u ct io n
In itially, th e exact position of th e rad ial h ead fragm en t was n ot To redu ce th is fractu re adequ ately, an open redu ction was
appreciated, su bsequ en tly, th e stan dard ESIN tech n iqu e was perform ed u sin g th e posterolateral approach . On ce th e h ead
in itiated. In th e rst procedu re, wh ich was perform ed u n der a was visu alized, it was fou n d to be vascu larized by on ly a very
gen eral an esth esia, a satisfactory redu ction was felt to h ave n arrow ap of per iosteu m . With th is degree of displacem en t
been obtain ed follow in g a closed m an ipu lative m an eu ver. th e r isk of avascu lar n ecrosis can be ver y h igh .

Th e stan dard 2.0 m m ESIN n ail w ith an extrem ely sh ar p tip Fin a l s t a b iliza t io n
was u sed. Th e n ail was in trodu ced th rou gh th e en tran ce site Th e radial h ead was carefu lly an d gen tly rotated arou n d its
an d advan ced retrograde in to th e radial diaphysis. On ce th e th in ped icle in order to ach ieve perfect redu ction . On ce a sat-
fractu re site h ad been reach ed, th e tip was orien ted in a lateral isfactory situ ation h ad been ach ieved, th e n ail tip was th en
an d posterior direction in an ticipation of en terin g th e h ead. advan ced in to th e radial h ead to ach ieve excellen t stability
( Fig 3 .5 -4 ).
Wh en th e n ail tip h ad reach ed th e fractu re site, a m ore carefu l
exam in ation of th e im ages revealed th at th e rad ial h ead was
“u pside dow n ”( Fig 3 .5 -3 ).

Fig 3.5 -3 “Upside dow n”. In th is Fig 3 .5 -4 Fin al stabiliza-

intraoperative im age, the articu lar tion . In th is lateral x-ray
su rface of the radial head is situ ated taken im m ediately post-
facin g the fractu re su rface of the operatively, th e h ead is
proxim al fragm en t. A clu e to th is an atom ically redu ced
reverse position in g of th e h ead is th e w ith th e tip of th e n ail
m etaphyseal fragm en t facin g the lyin g in th e su bch on dral
articu lar su rface of th e capitu lu m area of th e h ead frag-
(arrow). m en t.

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Becau se of th e sm all size of th e h ead fragm en t, th ere was con -

cern abou t postoperative stability. Th erefore, it was decided to
place th e extrem ity in a lon g-arm plaster cast for 6 weeks. Th e
fam ily was also in form ed of th e possibility th at avascu lar
n ecrosis of th e rad ial h ead m igh t develop.

68
 3 .5 Ra d ia l n e ck fra ct u re , co m p le t e ly d is lo ca t e d (21-E/ 2 .1-III)

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Fig 3 .5 -5 a – j 15-year-old fem ale; fell off h er bicycle an d Fig 3 .5 -6 a – iCom pletely displaced rad ial n eck fractu re in
on to h er ou tstretch ed arm . an 11-year-old girl. Closed, in d irect redu ction can be
a–b Th e in ju r y x-rays sh ow a d islocation of th e elbow dif cu lt. In th is situ ation , tran scu tan eou s m an ipu lation
join t w ith in itially u n d isplaced radial n eck fractu re. of th e rad ial h ead w ith a K-w ire w ill be possible. With th is
Closed redu ction was im m ed iately perform ed u n der so-called “joystick” tech n iqu e th e fragm en t can be
im age in ten si er con trol. At th is poin t in tim e, th e m an ipu lated in su ch a way th at th e fragm en t can later be
rad ial h ead was com pletely d isplaced posteriorly. en gaged by th e tip of th e n ail.
c– d Open redu ction was perform ed, xation of th e rad ial a – b AP an d lateral view s of th e fu lly d isplaced rad ial
h ead w ith two n ails to treat rotation al in stability. h ead.
Th e postoperative x-ray sh ow s persistin g rad ial h ead c– d Th e tran scu tan eou sly in serted K-w ire pu sh es th e
d islocation . rad ial h ead on to th e m etaph ysis.
e–f Secon dary in terven tion two days later; a bon e block e – f In traoperative x-rays sh ow perfect redu ction an d
from th e u ln a was in serted as bon e graft. align m en t.
g– j Th ere were n o sign s of h ealin g over th e n ext th ree g– h Postoperative x-rays at 2 m on th s sh ow good h ealin g.
m on th s, bu t also n o sign s of n ecrosis. Th e n ail was Th e ch ild n ever n eeded an add ition al restrain t
rem oved. Th e m obility of th e elbow is n orm al in th e plaster cast. Fu ll m obility was ach ieved.
absen ce of fractu re h ealin g. i Care m u st be taken to en su re th at th e K-w ire en ters
th e rad ial h ead an d does n ot ex it th rou gh th e
fractu re gap.

a b a b

c d e f c d

g h i j e f

g h i

69
 4 Fore arm

4 .1 In t ro d u ct io n —fo re a rm fra ct u re s 71
1 In d ica tio n 71
2 Pa tie n t p re p a ra tio n a n d p o sitio n in g 72
3 Su rgica l p rin cip le s 7 3
4 Im p la n t re m o va l 74
5 Su gge ste d re a d in g 7 5

4 .2 Mo n t e ggia le s io n (2 2 -D/ 6 .1) 77

4 .3 Fo re a rm s h a ft fra ct u re s , t ra n s ve rs e (12 -D/ 4 .1) 81

4 .4 Ra d ia l a n d u ln a r s h a ft fra ct u re s , d is p la ce d ra d iu s
w it h b u t t e r fly fra gm e n t , u ln a s im p le (12 -D/ 5 .2) 91

4 .5 Ra d ia l a n d u ln a r s h a ft fra ct u re s , m a lu n io n
fo llo w in g co n s e r va t ive t re a t m e n t (2 2 -D/ 4 .1) 95

4 .6 Ra d ia l a n d u ln a r s h a ft re fra ct u re a ft e r co n s e r va t ive
t re a t m e n t (2 2 -D/ 4 .1) 9 9

4 .7 Dis t a l ra d ia l a n d u ln a r d ia p h ys e a l-m e t a p h ys e a l
fra ct u re s , d is p la ce d (2 2 -D/ 4 .1) 10 3

70
4.1 Introduction —fore arm fracture s

1 In d ica t io n

Many fractu res of th e radial an d u ln ar sh afts are am en able to Mon teggia lesion s
con servative m an agem en t. However, m an y fractu re pattern s It is often d if cu lt to obtain or m ain tain rad ial h ead redu c-
are better treated w ith ESIN stabilization . An y su rgeon m an - tion u n less th e u ln a is an atom ically redu ced. Th is can be a
agin g th ese fractu res n eeds to be acqu ain ted w ith th e speci c problem particu larly if th ere is radial bow in g of th e u ln a.
su rgical in d ication s. Th ese are n ot depen den t on th e patien t’s Distal fractu re pattern s
age. In th e tran sition zon e of th e d istal m etaphysis to d iaph ysis
of th e rad iu s, ESIN is in d icated on ly if th e retrograde radial
Sp e ci c in d ica t io n s n ail can reach th e opposite in n er cortex of th e d istal frag-
Som e of th e de n ite in dication s for su rgical stabilization of m en t before crossin g th e fractu re lin e. Fu rth erm ore, an te-
rad ial an d u ln ar sh aft fractu res in clu de: grade n ailin g of th e rad iu s is NOT recom m en ded becau se
Com plete fractu res of both bon es of th e r isk of in ju r y to th e deep bran ch of th e radial n erve.
Th is is especially tru e if th e fractu res are on th e sam e Distal fractu res of th e u ln a can easily be stabilized w ith
level, h ave obliqu e fractu re plan es, or a con vergen t d is- th e stan dard an tegrade n ailin g approach .
placem en t. Th e m ore prox im al th e fractu re site, th e great- Refractu res
er th e th resh old to su rgical stabilization . It is best to avoid treatin g th ese n on operatively w h en ever
Green stick fractu re pattern s possible. Th is is becau se repeated im m obilization w ith a
Green stick fractu res of both sh afts m ay requ ire stabili- cast wou ld on ly fu rth er weaken th e u pper extrem ity m u s-
zation if redu ction an d stabilization w ith a cast does n ot cles th at are already weak from th e preced in g period of
ach ieve satisfactory align m en t. Th is is especially critical im m obilization .
if th e residu al an gu lation is greater th an 10° sin ce th ese Ipsilateral hu m eral fractu res
fractu res h ave a ten den cy to rean gu late to th eir in itial po- Open fractu res
sition . Polytrau m a
An isolated fractu re of th e rad iu s
Th ose isolated fractu res w ith an irredu cible valgu s devi-
ation of m ore th an 10°, wh ich can n ot be corrected by a
wedgin g of th e cast, w ill n eed to be su rgically stabilized.

71
 4 Fo re a rm

2 Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Th ese fractu res sh ou ld be treated as an em ergen cy on ly if

th ere is an open fractu re, n eu rovascu lar in ju ry, or im m in en t
perforation of th e sk in .

Me d ica t io n
With open fractu res, an tibiotic prophylaxis is de n itely re-
qu ired. With closed fractu res, an tibiotics are ad m in istered
accord in g to th e stan dards of th e clin ic protocol. Th rom bo-
sis proph ylax is is u tilized on ly in th ose patien ts im m obilized
becau se of mu ltiple in ju r ies or oth er gen eral diseases w ith
a b
risk factors su ch as obesity or th ose patien ts on con traceptive
m ed ication .

Pa t ie n t p o s it io n in g
Th e patien t is placed su pin e w ith th e arm on an arm table
( Fig 4 .1-1). If preferred, th e fractu re region can be placed
d irectly on th e C-arm receiver protected w ith a sterile cover.
Usin g sterile tech n iqu e th e in ju red extrem ity is su rgically
prepped an d draped to above th e elbow. Th e h an d m ay be
covered w ith a glove.

Eq u ip m e n t
In add ition to th e basic orth oped ic in stru m en ts, add ition al
specialized in stru m en ts an d im plan ts are n eeded to apply th e
ESIN tech n iqu e. Th ese in clu de:
Stan dard ESIN set
Nails:
2.0 –3.0 m m diam eter stain less steel or titan iu m ; each of
th e selected n ails sh ou ld be 2/ 3 th e d iam eter of th e rad ial Fig 4 .1-1a – c Patien t position in g.
an d/or u ln ar m edu llary can al at m idsh aft. a – b Illu stration s sh ow in g th e position in g of th e arm d irectly
Im age in ten si er: on th e C-arm receiver or on an arm table.
Th is sh ou ld be set u p in su ch a m an n er th at it does n ot in - c Correct placem en t of th e forearm directly on th e radio-
terfere w ith th e su rgical eld. To be m ost effective, it m u st lu cen t arm -side exten sion . Th e patien t h as been placed
be position ed so th at th e su rgeon h as a d irect view of th e as far laterally on th e table as possible.
m on itor.

72
 4 .1 In t ro d u ct io n —fo re a rm fra ct u re s

3 Su rgica l p rin cip le s

Th ere are th ree basic prin ciples th at n eed to be Na ilin g a p p ro a ch e s

con sidered wh en u sin g th e ESIN tech n iqu e in th e Th ere are speci c approach es available for n ailin g th e radial an d u ln ar
m an agem en t of fractu res of th e rad ial an d u ln ar sh afts.
sh aft. Th ese are: 1. Radiu s: retrograde n ailin g from a lateral or dorsal (rad ial tu bercle)
1. Th e ch oice of n ailin g approach es. en tran ce site ( Fig 4 .1-2 a – b ) is th e on ly tech n iqu e u tilized. It m u st be
2. Th e determ in ation of th e en tran ce sites. rem em bered th at an tegrade n ailin g of th e rad iu s is con train d icated.
3. Th e spread in g of th e in terosseou s m em bran e. 2. Uln a: th is can be ach ieved by on e of th e follow in g two tech n iqu es:
An tegrade from th e lateral cortex of th e olecran on ( Fig 4 .1-2 a – b ).
Retrograde from th e m ed ial cortex of th e d istal m etaph ysis
( Fig 4 .1–2c).

b c

a
f
Fig 4 .1-2 a – f Nailin g approach es.
a Retrograde n ailin g approach of th e rad iu s a n d b X-ray dem on stratin g h ealin g of sh aft fractu res follow in g th e u se of
an tegrade approach of th e u ln a. a retrograde rad ial an d an an tegrade u ln ar approach .
c X-ray dem on stratin g h ealin g of sh aft fractu res follow in g th e u se of
retrograde approach es for both th e rad iu s an d u ln a.
d – f X-rays sh ow in g th e process of a retrograde approach from th e m e-
dial cortex of th e d istal m etaphysis of th e u ln a.

73
 4 Fo re a rm

3 Su rgica l p rin cip le s (co n t )

En t ra n ce s it e s
Th e speci c location s of th e en tran ce sites for th ese approach es
w ill be described later in th e ch apters dealin g w ith each
in d ividu a l tech n iqu e.

In t e ro s s e o u s s p re a d in g
Th e in terosseou s m em bran e is spread in an oval fash ion by
placin g th e n ail tips in opposition so th at th ey are facin g each
oth er ( Fig 4 .1-3 ). Thu s, both bon es are stabilized by recreatin g
th eir ph ysiological cu r ve.

Fig 4 .1-3 In terosseou s spread in g. Sch em atic draw in g dem on -

stratin g spreadin g of th e in terosseou s m em bran e by d irectin g
th e n ail tips toward each oth er.

4 Im p la n t re m o va l

3 m on th s w ith th e n ails in place is su f cien t in m an y cases.

By 3 m on th s postin ju r y, th e x-rays sh ou ld sh ow fu ll con soli-

dation w ith com plete rem odelin g ( Fig 4 .1-4 ). At th is poin t,
n ail rem oval can be perform ed as an ou tpatien t procedu re. If
con solidation an d rem odelin g are n ot com plete, rem oval m ay
be postpon ed for an oth er m on th w ith ou t reservation . Som e
au th ors do n ot recom m en d rem oval before 8 m on th s postin -
ju ry becau se of th e risk of refractu re. In ou r ex per ien ce, th e
refractu re rate was n ot h igh er for th ose rem oved at 3 m on th s.
Sign i can t sk in irritation in th e im plan tation area requ irin g
prem atu re rem oval h as rarely been en cou n tered.

Fig 4 .1-4 a – bAP an d lateral x-rays taken 3 m on th s follow in g

ESIN stabilization of th is patien t dem on strate con solidation
an d rem odelin g su f cien t to perm it n ail rem oval. Note th at
a b
th ese n ails were both in serted via a retrograde approach .

74
 4 .1 In t ro d u ct io n —fo re a rm fra ct u re s

5 Su gge s t e d re a d in g

A ribit F, Lav ille J M (1999) Man n D , Sch n abe l M , Baacke M , e t al (2003)

Postero-m ed ial elastic stable in tram edu llary n ailin g for an te- [ Resu lts of elastic stable in tram edu llary n ailin g (ESIN) in
riorly d isplaced d istal d iaph yso-m etaphyseal fractu res of th e forearm fractu res in ch ild h ood.]
rad iu s in ch ild ren . Unfallchirurg; 106(2):102 –109.
Rev chir orthop; 85(8):858 –860. Mat t h e w s LS, Kau fe r H , Garve r D F, e t al (1982)
Fu lle r D J, McCu llo u gh CJ (1982) Th e effect on su pin ation -pron ation of an gu lar m alalign m en t
Malu n ited fractu res of th e forearm in ch ildren . of fractu res of both bon es of th e forearm .
J Bone Joint Surg; 64(3):364 –367. J Bone Joint Surg Am; 64(1):14 –17.
Hah n M P, R ich t e r D , Ost e rm an n PAW, e t al (1996) Ost e rm an n PA , R ich t e r D , Me ck le n bu rg K , e t al (1999)
[ Elastic in tram edu llary n ailin g—a con cept for th e m an age- [ Ped iatric forearm fractu res: in d ication s, tech n iqu e, an d
m en t of u n stable forearm fractu res in ch ildh ood.] lim its of con ser vative m an agem en t.]
Chirurg; 67(4):4 09 –412. Unfallchirurg; 102(10):784 –790.
K n o rr P, D ie t z HG (1999) Parsch K (1990)
Die elastisch stabile Markrau m sch ienu n g bei Sch aftfrak- Die Morote-Drah tu n g bei proxim alen u n d m ittleren Un ter-
tu ren des Un terarm s im Kin desalter–In d ikation en , Tech n ik, arm sch aftfraktu ren des Kin des.
Ergebn isse. Operat Orthop Traumatol; 2:245 –255.
Klin Pädiatr; 211:115. Sch m it te n be ch e r PP, D ie t z HG, Lin h art WE, e t al (2000)
Lae r L, Hasle r C (2000) Com plication s an d problem s in in tram edu llary n ailin g of
[Spon tan eou s correction s, grow th d isorders an d post- ch ildren s’ fractu res.
trau m atic deform ities after fractu res in th e area of th e Eur J Trauma; 26(6):287–293.
forearm of th e grow in g skeleton .] Sch m it t e n be ch e r PP (2004)
Handchir Mikrochir Plast Chir; 32(4):231–241. An alysis of rein terven tion s in ch ildren ’s fractu res—
Lasco m be s P, P re vo t J, Ligie r J N , e t al (1990) an aspect of qu ality con trol.
Elastic stable in tram edu llary n ailin g in forearm sh aft frac- Eur J Trauma; 30(2):10 4 –109.
tu res in ch ild ren : 85 cases. Tarr R R , Gar n ke l A I, Sarm ie n t o A
J Pediatr Orthop; 10(2):167–171. (198 4) Th e effects of an gu lar an d rotation al deform ities of
Le e S, N ico l RO, St o t t N S (2002) both bon es of th e forearm . An in -vitro stu dy.
In tram edu llary xation for ped iatr ic u n stable forearm frac- J Bone Joint Surg Am; 66(1):65 –70.
tu res. We in be rg A M , Kast e n P, Cast e lla n i C, e t al (2001)
Clin Orthop Relat Res; (402):245 –250. Wh ich ax ial deviation resu lts in lim itation s of pro- an d
Lie be r J, Jo e ris A , K n o rr P, e t al (2005) su pin ation follow in g d iaphyseal lower arm fractu res in
ESIN in forearm fractu res: clear in dication s often u sed, bu t ch ildh ood?
som e avoidable com plication s. Eur J Trauma; 27(6):309 –316.
Eur J Trauma; 31(1):3 –11.

75
 4 Fo re a rm

76
4.2 Monte ggia le sion (22-D/ 6 .1)

1 Ca s e d e s crip t io n

A 12-year-old boy fell at the playgrou nd, striking h is right forearm again st a bar (also
know n as n ightstick fractu re in North America). On presentation to the emergency
room , he clin ically h ad pain w ith rotation of the forearm and a visible an gu lar defor-
m ity involving the u ln ar aspect. The x-rays taken on adm ission showed a Bado type I
Monteggia lesion ( Fig 4 .2-1).

Fig 4 .2 -1a – b In ju ry x-rays.

a AP an d
b lateral x-rays sh ow in g th e ch aracteristic elem en ts of a Bado type I Mon teggia
lesion .

2 Su rgica l a p p ro a ch

An t e gra d e a p p ro a ch
To preven t th e occu rren ce of late u ln ar an gu lation
an d persistin g rad ial h ead d isplacem en t, th e u ln ar
fractu re is stabilized by an an tegrade approach .

Sk in in cis io n
A 2 cm in cision is m ade over th e lateral or rad ial
aspect of th e olecran on m etaph ysis startin g 2–3 cm
distal to th e apoph ysis. In cise directly to th e bon e.

En t ra n ce s it e
On ce th e bon e is ex posed, a sm all aw l is placed 90 º
to th e lateral cortex ( Fig 4 .2 -2 ). As th e aw l is d rilled
in to th e m edu llar y can al, it is gradu ally tilted in an
obliqu e d irection .
Fig 4 .2 -2 Th e tip of th e aw l is rst Fig 4 .2 -3 An tegrade in sertion
Na il in s e r t io n
placed 90 º to th e lateral cortex an d of th e n ail from th e lateral
A 2–2.5 m m n ail is in trodu ced in to th e en tran ce site
th en d irected obliqu e to 45° as it is en tran ce site in th e olecran on .
and advan ced distally to th e fractu re ( Fig 4.2-3 ).
u sed to drill th e en tran ce site.

77
 4 Fo re a rm

3 Re d u ct io n a n d fixa t io n

Fra ct u re re d u ct io n
On ce th e tip of th e n ail h as reach ed th e fractu re
site, it is rotated so th at it is poin tin g d irectly toward
th e cen ter of th e m edu llar y can al of th e opposin g
d istal fragm en t. Th e fractu re fragm en ts are align ed
by applyin g m anu al pressu re w ith th e n gers on
th e sk in d irectly over th e fragm en ts. Add ition al
m an ipu lation of th e proxim al fragm en t m ay be
ach ieved u sin g th e n ail as a h an d le ( Fig 4 .2 -4 ).

Dis t a l a d va n ce m e n t
On ce th e fractu re h as been align ed, th e n ail is th en
m anu ally advan ced slow ly in to th e d istal fragm en t.
As th e n ail is fed in to th e d istal fragm en t, it sh ou ld
correct th e deform ity of th e u ln a.

Ra d ia l h e a d re d u ct io n
Redu ction of th e u ln ar sh aft sh ou ld spon tan eou sly
redu ce th e radial h ead. Th e stability an d con gru -
en cy of th e rad ial h ead redu ction are con rm ed by
rotatin g th e forearm .

Fin a l s e a t in g
Th e n ail is cu t to place th e tip deep in th e su bcu ta-
n eou s tissu e. Th e wou n d is closed w ith on e or two
sin gle su tu res. To m ain tain th e spread of th e in ter-
osseou s m em bran e, th e tip sh ou ld be d irected
toward th e rad iu s ( Fig 4 .2 -5 ). 18 0 °

Fig 4 .2 -4 Prim ary u ln ar Fig 4 .2 -5 Fin al im plan ta-

redu ction . Th e sh aft of tion . Th e n ail is im plan ted
th e u ln a can be redu ced w ith th e tip d irected toward
w ith d irect pressu re on th e th e redu ced rad iu s.
sk in an d/or by u sin g th e
n ail as a h an dle.

78
 4 .2 Mo n t e ggia le s io n s (2 2 -D/ 6 .1)

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Ea rly re t u rn o f fu n ct io n Na il re m o va l
Sin ce n o extern al im m obilization is n ecessar y, free m ove- Th e n ail is rem oved 3 –4 m on th s after th e in ju ry, providin g th e
m en t can com m en ce w h en tolerated by th e patien t. If th e post- x-rays dem on strate com plete con solidation ( Fig 4 .2 -8 ). On ce
operative x-rays ( Fig 4 .2 -6 ) dem on strate satisfactor y align - fu ll fu n ction al recover y of th e forearm h as been ach ieved,
m en t, th e patien t can be d isch arged. If th e x-rays at 4 weeks fu rth er x-rays are n o lon ger n ecessar y.
dem on strate adequ ate con solidation of th e u ln ar fractu re
( Fig 4 .2 -7 ), sports activities are perm itted. Ro le o f p h ys io t h e ra p y
Ph ysioth erapy can be h elpfu l if m otion con tin u es to be re-
stricted for m ore th an 6 m on th s.

Im m ed iate AP an d lateral
Fig 4 .2 -6 a – b Fig AP an d lateral x-rays
4 .2 -7a – b Fig 4 .2 -8 a – bAP an d lateral x-rays at
postoperative x-rays. Th e radial h ead taken at 4 weeks sh ow early callu s an d 4 m on th s dem on strate fu ll h ealin g an d
d islocation is redu ced. m ain ten an ce of th e redu ction s. con siderable con solidation of th e u ln ar
fractu re alon g w ith m ain ten an ce of th e
rad ial h ead redu ction . Th e n ail can n ow
be rem oved.

79
 4 Fo re a rm

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
An tegrade n ailin g of th e m ore prox im al fractu res of th e A distal en tran ce site is preferable in th ose Mon teggia
u ln a m ay lead to an u n satisfactory redu ction . lesion s in wh ich th e u ln ar fractu re is prox im al.

Exam ple of a Bado

Fig 4 .2 -10 a – b
type III Mon teggia lesion w ith a
very prox im al u ln ar fractu re.

Fig 4 .2 -11a – b For th ese proxim al

u ln ar fractu res, retrograde n ailin g
is preferable. Th e x-rays sh ow
redu ction of th e u ln ar fractu re an d
th e rad ial h ead follow in g retro-
grade n ailin g.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Fig 4 .2 -9 a – d Persistent displacement of the radial head • Con trol th e correct position of th e rad ial h ead in ten -
can lead to a poor outcome. The m ajor cau se is u su ally a sively u sin g im age in ten si er du rin g rotation
residu al deform ity of the u ln a. On rare occasion s the radial of th e forearm an d exion /exten sion of th e elbow.
head does not reduce spontaneou sly even though the • If th e rad iu s is n ot spon tan eou sly redu ced, try d irect
u ln a is well aligned (c). redu ction by extern al pressu re on th e prox im al
rad iu s.
• If redu ction is n ot reliable, pu ll ou t th e n ail an d
ben d it to effect a m ore effective an d powerfu l cou n ter-
m ovem en t again st th e in itial u ln ar m alalign m en t.
• If bow in g of th e u ln a w ith ou t an y visible fractu re
is th e cau se of on goin g rad ial d isplacem en t, u se a
stron g, well preben t u ln ar n ail. Th e ten sion w ith in th e
n ail redu ce th e plastic deform ation of th e u ln a du rin g
c d
th e follow in g days.

Po s to p e ra t ive ca re a n d re h a b ilit a t io n Po s to p e ra t ive ca re a n d re h a b ilit a t io n

Early or aggressive ph ysioth erapy carr ies a h igh r isk of Ph ysioth erapy sh ou ld be avoided for th e rst 6 m on th s
produ cin g h eterotopic ossi cation arou n d th e elbow. after th e inu r y.

80
4.3 Fore arm shaft fracture s, transve rse (12-D/ 4.1)

1 Ca s e d e s crip t io n

8-year-old boy fell from a tree an d presen ted clin ically w ith
an an gu lated righ t forearm . Th e x-rays dem on strated d is-
placed an d sh orten ed tran sverse fractu res of th e rad ial an d
u ln ar sh afts at n early th e sam e level ( Fig 4 .3 -1)

Fig 4 .3 -1a – c
a Clin ical appearan ce. On presen tation , th ere was an
obviou s apex-dorsal an gu lation in th e righ t forearm .
b – c AP an d lateral x-rays sh ow com plete fractu res of th e
d istal sh afts of both th e radiu s an d u ln a w ith sh orten in g
an d an gu lation .

2 Su rgica l a p p ro a ch

Se p a ra t e s it e s ex pose th e tu bercle. After retractin g th e in cision , th e aw l is

Su rgical stabilization of th e rad ial an d u ln ar sh afts requ ires placed d irectly on th e tu bercle adjacen t to th e th ird com part-
separate stan dard in sertion sites, on e at each en d of th e fore- m en t con tain in g th e exten sor ten don s. Care is taken to avoid
arm . Th e radial site is distal an d th e u ln ar site is proxim al. in ju ry to th e ten don s. Th e aw l is d irected an terom ed ially as it
is d rilled to perforate th e posterior cortex ( Fig 4 .3 -3 ). At th is
Dis t a l d o rs a l ra d ia l n a il in s e r t io n poin t it is im portan t to be carefu l n ot to perforate th e opposite
A 2 –3 cm tran sverse or lon gitu d in al in cision is m ade over cortex. Th e n ail is in trodu ced an d advan ced prox im ally to th e
th e palpable dorsal tu bercle of th e rad iu s ( Fig 4 .3 -2 ). Next, fractu re site ( Fig 4 .3 -4 ).
th e su bcu tan eou s tissu e is spread an d th e fascia is in cised to

81
 4 Fo re a rm

2 Su rgica l a p p ro a ch (co n t)

Fig 4 .3 -2 Rad ial in cision .

Sm all tran sverse sk in in ci-
sion m ade over th e posterior
aspect of th e dorsal tu bercle
of th e rad iu s (altern atively
lon gitu din al in cision).

Fig 4 .3 -3 Th e rad ial en tran ce site is m ade w ith th e aw l rst Fig 4 .3 -4 a – b

placed per pen d icu lar to th e posterior cortex of th e tu bercle a Rad ia l n ail in sertion . Th e rad ial n ail is in serted in to th e
an d th en directed 45° to en ter th e m edu llar y can al. en tran ce site an d advan ced u sin g th e T-h an dled h an d
chu ck.
b Rad ia l n ail advan cem en t. Follow in g its in sertion , th e
radial n ail is advan ced to ju st sh ort of th e fractu re site.

82
 4 .3 Fo re a rm s h a ft fra ct u re s , t ra n s ve rs e (12 -D/ 4 .1)

2 Su rgica l a p p ro a ch (co n t)

Pro xim a l u ln a r in s e rt io n th e aw l d irected obliqu ely in a d istal d irection ( Fig 4 .3 -5 a ).

Th e sk in is in cised 1.5 –2 cm tran sversely over th e proxim al Th e n ail is in serted an d advan ced d istally to th e fractu re site
lateral aspect of th e olecran on , 3 cm d istal to th e apoph y- ( Fig 4 .3 -5b ).
sis. Th e lateral cortex of th e olecran on is perforated w ith

a b

Fig 4 .3 -5 a – b
a Uln ar en tran ce site. b Uln ar n ail advan cem en t.
Th e u ln ar site is created on th e lateral su rface Usin g th e in serter, th e
of th e olecran on by drillin g w ith th e aw l rst u ln ar n ail is advan ced
per pen dicu lar to th e cortex an d th en gradu ally to ju st sh ort of th e u ln ar
an gu latin g it to en ter th e m edu llary can al. fractu re site.

83
 4 Fo re a rm

3 Re d u ct io n a n d fixa t io n

3 .1 St a n d a rd t e ch n iq u e —ra d iu s n ail is advan ced proxim ally to th e level of th e radial tu beros-

ity. Th e tip sh ou ld be d irected toward th e u ln a ( Fig 4 .3 -7 ).
Sin gle re d u ct io n
Becau se it is often th e m ore dif cu lt step, th e rad iu s sh ou ld be Op e n re d u ct io n
redu ced rst. Attem pt to brin g th e fractu re plan es in con tact Failu re to in trodu ce th e n ail in to th e prox im al fragm en t
in d irectly by percu tan eou sly m an ipu latin g th e proxim al frag- requ ires an open redu ction . To do so, m ake a sh ort in cision at
m en t. Rotate th e rad ial n ail carefu lly to lin e u p th e tip per- th e level of th e fractu re to rem ove th e obstru ctin g soft tissu e.
fectly to th e m edu llary can al of th e prox im al fragm en t an d Un der d irect vision , redu ce th e fractu re w ith sm all clam ps
th en advan ce th e tip in to th e prox im al fragm en t ( Fig 4 .3 -6 ). an d th en advan ce th e tip of th e n ail in to th e prox im al frag-
On ce passage of th e n ail in to th e can al h as been veri ed, th e m en t ( Fig 4 .3 -8 ).

Fig 4 .3 -6Rad ial redu ction . Fig 4 .3 -7 Rad ial position in g. Fig 4 .3 -8 Open redu ction .
On ce redu ction of th e rad iu s h as been Th is n ail is advan ced prox im ally Failu re to ach ieve a closed reduc-
ach ieved, th e rad ial n ail is advan ced in to to th e level of th e rad ial tu beros- tion m ay requ ire exposu re of the
th e proxim al fragm en t. ity. Th e tip is d irected toward th e fractu re site th rou gh a sm all in ci-
u ln a. sion to visu alize passage of the tip
in to th e proxim al fragm en t.

84
 4 .3 Fo re a rm s h a ft fra ct u re s , t ra n s ve rs e (12 -D/ 4 .1)

3 Re d u ct io n a n d fixa t io n (co n t)

3 .2 St a n d a rd t e ch n iq u e —u ln a Sim u lt a n e o u s re d u ct io n
If redu ction of th e rad iu s an d/or u ln a is d if cu lt, it m ay be
Sin gle re d u ct io n h elpfu l in itially to on ly advan ce th e radial n ail as far as th e
Follow in g redu ction of th e radiu s, th e u ln a u su ally redu c- fractu re site. Th en , proceed w ith th e in sertion of th e u ln ar
es spon tan eou sly. Th e u ln ar n ail is advan ced distally to th e n ail. Now, th e redu ction can often be accom plish ed m ore
distal u ln ar m etaphysis. It is th en secu red in th e stron g can cel- easily becau se both n ails can be m an ipu lated simu ltan eou sly.
lou s m etaphyseal bon e w ith th e tip rotated toward th e radiu s
to produce m axim al spreadin g of th e in terosseou s m em bran e 3 .3 Fin a l p o s it io n o f b o t h n a ils
( Fig 4 .3 -9 ). On rare occasion s th e u ln a m ay n eed an open
Th e n ails are cu t an d th eir en ds placed deep in th e su bcu tan e-
redu ction in th e sam e m an n er as described for th e rad iu s.
ou s tissu e. Th e in cision s are th en closed w ith sin gle su tu res
( Fig 4 .3 -10 ). Th e en d of th e rad ial n ail m u st be placed su f -
cien tly ou tside th e ten don com partm en t to preven t con stan t
friction an d ten don ru ptu re.

18 0 °

a b c

Fig 4 .3 -9 Uln ar position in g. After cu ttin g th e n ails to th e proper len gth , th e

Fig 4 .3 -10 a – c
Th e u ln ar n ail is advan ced d istally to seat th e tip in th e m e- en ds are bu ried u n der th e su bcu tan eou s tissu es. Notice th e
taph ysis. Th e tip sh ou ld be d irected toward th e rad iu s. spreadin g effect on th e in terosseou s m em bran e produ ced by
cen tral poin tin g of th e tips (see Fig 4 .1-3 ).

85
 4 Fo re a rm

3 Re d u ct io n a n d fixa t io n (co n t)

3 .4 Alt e rn a t ive t e ch n iq u e s —ra d iu s

Man y su rgeon s prefer to in sert th e radial n ail by a lateral

approach on th e d istal radiu s. Th e in cision h ere n eeds to be
a little lon ger in order to iden tify an d protect th e su per cial
rad ial n er ve. Th e aw l m u st carefu lly be placed d irectly on th e
lateral cortex ( Fig 4 .3 -11).

Fig 4 .3 -11 Lateral rad ial in cision . Altern atively, th e d istal

rad ial en tran ce site can be placed in th e lateral cortex. It is
im portan t to be su re th at th e in cision is lon g en ou gh to visu -
alize an d retract th e su per cial rad ial n erve.

3 .5 Alt e rn a t ive t e ch n iq u e s —u ln a

In sertion of th e u ln ar n ail in its d istal m etaph ysis is favored

by m an y su rgeon s. An in cision is placed over th e d istal
m edial u ln ar m etaph ysis. Th e m edu llary can al is open ed w ith
th e aw l an d th e n ail is in trodu ced an d advan ced in retrograde
tech n iqu e (see ch apter 4.6, Fig 4 .6 -2 to Fig 4 .6 -5 ). Man ipu lati-
on of both bon es from th e sam e en d m ay be h elpfu l in redu -
cin g d if cu lt fractu re pattern s.

Fig 4 .3 -12 a – d
a – b Both n ails are in trodu ced retrograde th rou gh th e
en tran ce site in th e d istal m etaph ysis. Postoperative x-
rays dem on strate ESIN stabilization w ith correct ax ial
align m en t.
c– d Detailed view of th e d istal u ln ar en tr y poin t on im age
in ten si er.

86
 4 .3 Fo re a rm s h a ft fra ct u re s , t ra n s ve rs e (12 -D/ 4 .1)

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Ea rly m o t io n a llo w e d callu s form ation ( Fig 4 .3 -15 ) to perm it participation in sports.
Th e postoperative x-rays dem on strate a satisfactory n al At 3 m on th s postin ju ry, th e x-rays dem on strate su f cien t
align m en t ( Fig 4 .3 -13 ). Becau se n o postoperative im m obi- con solidation an d rem odelin g to sch edu le n ail rem oval
lization is requ ired, active m otion can com m en ce as toler- ( Fig 4 .3 -16 ). In m ost cases, th ere is fu ll fu n ction al recovery
ated ( Fig 4 .3 -14 ). X-rays 4 weeks later dem on strate su f cien t ( Fig 4 .3 -17 ).

Postoperative x-rays tak-

Fig 4 .3 -13 a – b Fig 4 .3 -14Alm ost fu ll recovery of elbow X-rays at 4 weeks sh ow
Fig 4 .3 -15 a – b
en im m ediately after ESIN stabilization . m otion 5 days after ESIN stabilization of early callu s form ation .
the radial and u ln ar sh afts.

AP an d lateral x-rays taken 3 m on th s

Fig 4 .3 -16 a – b Th is you n g boy h as recovered fu ll su pin ation ( a )
Fig 4 .3 -17a – b
later prior to rem oval of th e n ails. Alm ost com plete an d pron ation ( b ).
rem odelin g of th e fractu re site.

87
 4 Fo re a rm

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Avoid perform in g th e posterior rad ial approach totally In cisin g th e sk in su f cien tly an d retractin g it w ith
percu tan eou sly (w ith ou t a su rgical in cision) as th is m ay sm all h ooks to allow placem en t of th e aw l u n der d irect
in ju re on e of th e exten sor ten don s. view w ill preven t th is com plication .

Take great care n ot to perforate th e opposite cortex Accen tu ation of th e cu r ve of th e n ail tips w ill facilitate
wh en in sertin g th e aw l. Perforatin g th e cortex th eir glid in g off th e in n er su rface of th e opposite
w ill produ ce an abn orm al passageway th at w ill gu ide m etaph yseal cortex. Th is w ill gu ide th e tip in to th e
th e n ail in to th e vital an terior or m ed ial soft tissu es m edu llar y can al.
wh ich can th en becom e in ju red.

Always be su re th at th e cu t en d of th e n ail lies Th e posteriorely im plan ted rad ial n ail sh ou ld be lon g
ou tside th e ten don com partm en t. A secon dar y ten don en ou gh to lie ou tside th e exten sor ten don com partm en t
in ju ry cou ld arise from con stan t ru bbin g again st in th e su bcu tan eou s tissu e.
th e sh ar p en d of n ail ( Fig 4 .3 -18 ).

Fig 4 .3 -18 Ten don ru ptu re. In th is case

th e exten sor pollicis lon gu s ten don
was ru ptu red by ru bbin g again st th e
sh ar p edge of th e sh ort rad ial n ail.
Th is h appen s if th e d irection of th e n ail
is very at an d th e n ail is cu t very sh ort.

Avoid im plan tation of th e u ln ar n ail directly th rou gh In sert th e u ln ar n ail th rou gh th e lateral cortex of th e
th e olecran on apoph ysis. Th e cu t en d of th e n ail olecran on a few cen tim eters distal to th e tip.
w ill lie very su per cially wh ich wou ld allow it to perfo-
rate th e sk in easily.

An tegrade rad ial n ailin g w ith its prox im al in sertion

carries a h igh risk of in ju ry to th e deep bran ch of
th e rad ial n er ve. Th is approach an d tech n iqu e sh ou ld
n ever be u sed!

88
 4 .3 Fo re a rm s h a ft fra ct u re s , t ra n s ve rs e (12 -D/ 4 .1)

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Too aggressive m an ipu lation of In th ose areas wh ere th e m edu llary can al is very
th e n ail at th e fractu re site can blow n arrow, advan ce th e n ail on ly by h an d. Do n ot u se a
ou t a sm all fragm en t, m ak in g it h am m er. Do n ot tr y to advan ce th e n ail by force
dif cu lt to align th e fractu re. if th ere is a lot of resistan ce. Th e n ail can be advan ced
by gradu ally rotatin g its tip.

Fig 4 .3 -19 Fractu re blow-ou t.

Forcin g a n ail th rou gh th e n arrow
diaph yseal can al u sin g a h am m er
can produ ce a blow-ou t fragm en t.

Re h a b ilit a tio n Re h a b ilit a tio n

Th ere is a h igh risk of refractu re if prem atu re
rem oval of th e n ails is perform ed before th ere is
de n itive con solidation of th e fractu re.

Rem oval sh ou ld n ot be perform ed u n til

Fig 4 .3 -2 0 a – b
th ere is x-ray eviden ce of solid u n ion an d rem odelin g at
th e fractu re site.

89
 4 Fo re a rm

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Re h a b ilit a tio n (co n t)

If sign i can t restriction of pron ation or su pin ation
con tinu es for m ore th an 3 m on th s after n ail rem oval,
ph ysioth erapy sh ou ld be in itiated w ith close su pervision
u n til fu ll fu n ction al recover y h as been ach ieved.

Fig 4 .3 -21a – c Patien t dem on stratin g lim itation of su pi-

n ation (a ) an d pron ation ( b ). Notice th e com pen sation by
th e sh ou lder (c).

90
4.4 Radial and ulnar shaft fracture s, displace d radius
with butte r y fragm e nt, ulna sim ple (12-D/ 5.2)
1 Ca s e d e s crip t io n

A 14-year-old m ale in volved in a scooter acciden t presen ted

w ith a visible an gu lar deform ity of h is righ t forearm . His
x-rays dem on strated displaced radial an d u ln ar sh aft fractu res
w ith a large bu tter y fragm en t of th e radiu s an d a tran sverse
fractu re of th e u ln a ( Fig 4 .4 -1).

Fig 4 .4 -1a – bSch em atic represen tation dem on stratin g th e

acu te fractu re pattern w ith th e presen ce of a large bu tter y
fragm en t in th e m idsh aft of th e rad iu s.
a AP view.
b Lateral view.

Pre re q u is it e s fo r ESIN s t a b iliza t io n

ESIN can be perform ed w ith th ese fractu re pattern s, provid-
in g th e m ain fragm en ts of th e rad iu s m ain tain both adequ ate
a b con tact an d len gth , an d th e align m en t can be stabilized.

2 Su rgica l a p p ro a ch

St a b iliza t io n o f t h e ra d iu s St a b iliza t io n o f t h e u ln a
Start w ith th e rad iu s, u tilizin g th e sam e approach as dem - Uln a stabilization . After th e rad ia l n ail is well secu red in
on strated in th e case presen ted in ch apter 4.3 Forearm sh aft th e region of th e rad ial n eck, th e u ln a is stabilized as ou t-
fractu res, tran sverse (see Figs 4 .3 -3 to 4 .3 -7 ). Stabilization of lin ed in th e aforem en tion ed case in ch apter 4.3 Forearm
th e rad iu s sh ou ld be com pleted prior to stabilization of th e sh aft fractu res, tran sverse (see Figs 4 .3 -5 to 4 .3 -9 ). As an al-
u ln a to be su re th at a satisfactor y redu ction can be ach ieved. tern ate tech n iqu e, d istal retrograde im pla n tation of th e u l-
n ar n ail can be satisfactorily accom plish ed as described in
Figs 4 .3 -3 to 4 .3 -5 .

91
 4 Fo re a rm

3 Re d u ct io n a n d fixa t io n

Ra d ia l s t a b iliza t io n Pro xim a l in s e r t io n

Reach in g th e fractu re region , rotate th e tip of th e n ail so th at In sert th e n ail in to th e prox im al m edu llary can al an d advan ce
a d isplacem en t of th e wedge is avoided. If th e tip of th e n ail it prox im ally to th e area of th e rad ial n eck ( Fig 4 .4 -3 ). At th is
faces th e tip of th e wedge, th e n ail m ay glide alon g th e base poin t evalu ate th e align m en t an d stability of th e redu ction of
side of th e wedge. th e radiu s. Th e wedge can rem ain in its origin al position in
th e su rrou n din g soft tissu e, as lon g as it does n ot im pin ge on
Dire ct m a n ip u la t io n th e in terosseou s m em bran e.
Extern ally reduce the m ain fragments by directly m an ipu lating
the distal fragment w ith the im planted n ail to brin g the planes of
the fractu re fragments into direct apposition ( Fig 4.4 -2 ).

18 0 °
18 0 °

18 0 °
a b a b

Fig 4 .4 -2 a – b Fig 4 .4 -3 a – b
a Th e fragm en ts are m an u ally redu ced an d h eld as th e tip of a Stabilization of th e rad iu s is com pleted by advan cin g th e
th e n ail is in trodu ced in to th e fractu re site. At th is poin t n ail tip proxim ally to th e level of th e radial n eck.
th e n ail sh ou ld glide on th e base of th e bu tter y to facili- b Uln ar stabilization . Th e n ail is th en in serted in to th e prox-
tate en tran ce in to th e fragm en t. im al u ln a an d passed an tegrade to th e fractu re site.
b On ce th e fragm en t h as been en tered, th e n ail is rotated to
place th e blu n t su rface again st th e in tact cortex of th e frag-
m en t so as to avoid displacin g it.

92
 4 .4 Ra d ia l a n d u ln a r s h a ft fra ct u re s , d is p la ce d ra d iu s w it h b u t t e r fly fra gm e n t , u ln a s im p le (12 -D/ 5 .2)

3 Re d u ct io n a n d fixa t io n (co n t)

Fin a l n a il p la ce m e n t
On ce th e rad iu s is align ed, th e u ln ar n ail can easily be
advan ced an tegrade in to th e d istal fragm en t ( Fig 4 .4 -3 ). In th e
n al position , th e tips of both n ails are directed toward th e
in terosseou s m em bran e. Th e blu n t en ds of th e n ails are cu t at
th e correct len gth an d are bu ried in th e su bcu tan eou s tissu e.
Th e sk in is closed w ith sin gle su tu res ( Fig 4 .4 -4 ).

If th ere is in su f cien t stability to allow u n protected m otion ,

ESIN sh ou ld be aban don ed an d th e fractu re stabilized by
oth er m ean s su ch as an extern al xator. Th erefore, stability
h as to be proven before th e en d of an esth esia.

Fig 4 .4 -4 a – b After h avin g redu ced th e fractu re an d advan ced

th e u ln ar n ail d istally to th e d istal m etaph ysis, th e blu n t en ds
of both n ails are cu t to leave on ly a sm all portion ou tside th e
cortex. Notice th at th e tips of both n ails are d irected toward
th e in terosseou s m em bran e to en h an ce th e stability.
a b

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Mo b ilit y e n co u ra ge d
Postoperative cast im m obilization is n ot n ecessary. Con trol
x-rays sh ou ld be taken prior to d isch arge ( Fig 4 .4 -5 ).

Fig 4.4 -5a – bPostoperative x-rays show ing the anterior wedge
w ithout interposition into the interosseou s mem brane.
a AP view.
b Lateral view.

93
 4 Fo re a rm

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n (co n t)

Fra gm e n t in co rp o ra t io n
X-rays obtain ed 4 weeks later sh ou ld con rm
good callu s form ation w ith in cor poration of
th e wedge ( Fig 4 .4 -6 ). Forearm rotation is
evalu ated clin ically. It is ex pected th at th ere
m ay still be som e lim itation at th is tim e. By
4 m on th s postoperative, th e wedge sh ou ld
be com pletely rein tegrated an d rem odeled
in to th e m ain fragm en t ( Fig 4 .4 -7 ).

Fin a l fo llo w -u p
On ce th e fractu re is fu lly con solidated, th e
n ails can be safely rem oved. Th e patien t
sh ou ld be followed clin ically u n til a satisfac-
tory fu n ction al ou tcom e h as been ach ieved.

Fig 4 .4 -6 a – b AP an d lateral x-rays Fig 4 .4 -7a -b AP an d lateral x-rays

at 4 weeks. at 4 m on th s.

5 Pit fa lls – 6 Pe a rls +

Re d u ctio n a n d xa t io n Re d u ct io n a n d xa t io n
Th e rad ial n ail is u n able to straigh ten an d/or stabilize Th e ax ial recon stru ction of th e rad iu s sh ou ld be evalu -
th e rad iu s in to a satisfactory an atom ical align m en t ated by rotatin g th e forearm u n der real-tim e im age
becau se th ere is in su f cien t con tact of th e m ain frag- in ten si cation . If stability h as n ot been ach ieved, th e
m en ts. Th is allow s th e con tactin g fragm en t tips to stabilization tech n iqu e sh ou ld be con verted to an oth er
slide alon g each oth er. m eth od, su ch as an extern al xator.

In traoperatively, th e wedge is displaced sign i can tly Su rgically explore th e fractu re site an d brin g th e wedge
between rad iu s an d u ln a to com prom ise forearm in to better con tact to th e rad iu s.
rotation .
If th e position of th e wedge alon e was th e problem an d
th e su rgical stabilization is acceptable, th e origin al tech -
n iqu e n eed n ot be ch an ged.

Re h a b ilit a t io n Re h a b ilit a tio n

Too early m obilization w ith sports or load in g activities In m u ltifragm en tary fractu res, postoperative reh abilita-
resu lts in a secon dary d isplacem en t. tion m ay h ave to be restricted to preven t red isplacem en t.

94
4.5 Radial and ulnar shaft fracture s, m alunion following
conse rvative tre atm e nt (22-D/ 4.1)
1 Ca s e d e s crip t io n

A 6-year-old boy su stain ed displaced fractu res of th e left

rad ial an d u ln ar sh afts. He h ad previou sly u n dergon e con ser-
vative treatm en t at an oth er m ed ical facility w ith a lon g-arm
22°
cast for 4 weeks. X-rays on com pletion of h is treatm en t re-
vealed u n ited fractu res w ith sign i can t m alalign m en t
( Fig 4 .5 -1 ). Clin ically, th ere was severe restriction of su pin a-
tion an d pron ation .

ESIN gives th e opportu n ity to correct th e m alalign m en t

15 °
in d irectly w ith ou t osteotom y as lon g as th e m edu llar y can al
is visible.

Fig 4 .5 -1a – bX-rays taken after cast rem oval sh owed 15° of
an gu lation of th e rad ial sh aft an d 22° of th e u ln ar sh aft. Th e
fractu re sites were u n ited w ith abu n dan t callu s.
a Lateral view.
a b
b AP view.

2 Su rgica l a p p ro a ch

Both n ails can be im plan ted as described previou sly in th e

case presen ted in ch apter 4.3 Forearm sh aft fractu re, tran s-
verse (see Figs 4 .3 -3 to 4 .3 -10 ). If th e redu ction of th e rad iu s
(or of th e u ln a) is n ot su f cien t to allow in sertion of th e n ail
in to th e in tram edu llar y can al of th e prox im al fragm en t, th en
an open redu ction n eeds to be perform ed. Often in previou s
h ealed fractu res, th e m edu llary can al is obstru cted by callu s
wh ich m ay requ ire an open approach an d drillin g to facilitate
passage of th e n ail tip.

95
 4 Fo re a rm

3 Re d u ct io n a n d fixa t io n

Su rgica l e xp o s u re
Th e n ail is in serted in to th e d istal rad iu s via a dorsal en tran ce
site an d advan ced to ju st sh ort of th e fractu re site. Th e frac-
tu re site of th e rad iu s is th en ex posed su rgically th rou gh
a 3 –4 cm sk in in cision . Next, th e fascia is open ed an d th e
tissu e plan es between th e forearm exten sor an d thu m b exor
m u scles are separated carefu lly to ex pose th e fractu re frag-
m en ts ( Fig 4 .5 -2 ). Th e in ter posed m u scle tissu e is rem oved
to clear an d free th e fragm en ts. On ce th e soft-tissu e im ped i-
m en ts h ave been rem oved, th e fractu re can easily be redu ced
w ith a sm all h ook or clam p. At th is poin t th e n ail can easily be
in trodu ced in to th e m edu llary can al an d advan ced prox im ally Fig 4 .5 -2 Open redu ction . Follow in g ex posu re of th e fractu re
to th e rad ial n eck. Th e fractu re is th en m an aged to com plete site th rou gh a 3 –4 cm sk in in cision , th e fractu re is redu ced
th e osteosyn th esis as in th e case presen ted in ch apter 4.3 Fore- w ith sm all redu ction forceps to facilitate d irect in trodu ction of
arm sh aft fractu res, tran sverse (see Figs 4 .3 -8 to 4 .3 -10 ). th e n ail in to th e m edu llar y can al of th e prox im al fragm en t.

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Th e postoperative m an agem en t is th e sam e as previou sly

described w ith rou tin e radial an d u ln ar sh aft fractu res. Post-
operative an d follow-u p cou rse is sh ow n in Figs 4 .5 -3 to 4 .5 -5 .
Th e x-rays at 3 m on th s u su ally dem on strate com plete h ealin g
an d rem odelin g ( Fig 4 .5 -5 ) su f cien t to allow n ail rem oval. If,
h owever, th ere is in su f cien t callu s form ation , rem oval of th e
n ails sh ou ld be postpon ed.

X-rays taken im m ediately postoperatively sh ow

Fig 4 .5 -3 a – b
correction of th e an gu lar deform ity.

96
 4 .5 Ra d ia l a n d u ln a r s h a ft fra ct u re s , m a lu n io n fo llo w in g co n s e r va t ive t re a t m e n t (2 2 -D/ 4 .1)

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n (co n t)

X-rays taken at 4 weeks

Fig 4 .5 -4 a – b X-rays taken at 3 m on th s:
Fig 4 .5 -5 a – b
sh ow early obliteration of th e fractu re th ere was su f cien t obliteration of th e
lin e an d early callu s. fractu re lin e an d rem odelin g of th e
callu s to allow n ail rem oval.

5 Pit fa lls – 6 Pe a rls +

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Usin g an in cision at th e fractu re site th at is too sh ort for Becau se of th e n eed to perform vigorou s retraction w ith
th e open redu ction . a sm all in cision , th ere m ay be m ore soft-tissu e trau m a
w ith a sh ort in cision th an w ith an adequ ate sk in in cision
wh ich easily provides su fficien t visu alization of th e tis-
su es in volved.

Makin g too m any attem pts to obtain a redu ction by The treatin g su rgeon needs to u nderstand th at there is a
closed m an ipu lation . risk of soft-tissue in ju ry plu s radiation exposu re by repeated
u n successfu l m an ipu lation s to ach ieve a closed reduc-
tion . These risks need to be weighed again st the relatively
controlled soft-tissue trau m a of an open reduction . The
decision to perform an open procedu re is determ ined by the
su rgeon’s judgment and skill.

97
 4 Fo re a rm

98
4.6 Radial and ulnar shaft re fracture afte r conse rvative
tre atm e nt (22-D/ 4.1)
1 Ca s e d e s crip t io n

9-year-old boy wh o fell over 2 m on th s after cast rem oval.

Refractu res of th e rad ial an d u ln ar sh afts of h is previou sly
con servatively treated fractu res.

Fig 4 .6 -1a – b AP an d lateral x-rays sh ow in g refractu res of th e

a b
sh afts of th e rad iu s an d u ln a.

2 Su rgica l a p p ro a ch

Drillin g o f ca n a l
Refractu res in th e rad ial an d u ln ar sh afts can be stabilized
w ith ESIN u sin g th e sam e tech n iqu e as th at u sed for th e
m alalign ed fractu res. Closed redu ction of th ese refractu res
m ay be d if cu lt becau se th e en ds of th e fragm en ts m ay be
covered w ith callu s. If a good in tram edu llary can al is n ot
iden ti able on th e x-ray, ESIN m ay n ot be possible by closed
m eth ods. Th e m edu llary can als h ave to be cleared by drillin g
th e ex posed fractu re su rfaces.

99
 4 Fo re a rm

2 Su rgica l a p p ro a ch (co n t)

Re t ro gra d e a p p ro a ch the u ln a via the retrograde approach , a 2–3 cm incision over

Again , if im plantation of the n ails of on e or both of the forearm the distal u ln a is m ade startin g 3 cm proxim al to the palpable
bon es is expected to be dif cu lt, it m ay be best to approach u ln ar styloid ( Fig 4 .6 -2 ). The dissection is carefu lly continued
both th e radiu s an d u ln a “in th e sam e direction”. Th is wou ld directly to the bone. The awl is placed 90° to the u ln a and then
requ ire a retrograde approach for both fractu res. Th e radiu s is drilled obliquely to produce th e en trance site, takin g care to
rst stabilized via th e stan dard retrograde approach . To stabilize preven t perforation of th e opposite cortex ( Fig 4 .6 -3 ).

Fig 4 .6 -2 Distal skin inci-

sion s. The radiu s h as been sta-
bilized by the standard retro- Fig 4 .6 -3 Uln ar entrance site.
grade approach w ith a dorsal In creatin g the entrance site
distal entran ce site. The distal in the distal u ln a, the awl is
u ln ar entrance site is m ade directed obliquely proxim al to
w ith th e awl u sin g an incision facilitate the in itial passage of
3 cm proxim al to the prom i- the n ail and avoid penetration
nence of the u ln ar styloid. of the opposite cortex.

3 Re d u ct io n a n d fixa t io n

The n ail is in serted and care- Th is in sertion sh ou ld be perform ed w ith cau tion
fu lly advanced proxim ally in becau se of th e sm all m edu llar y can al. If th e stabi-
retrograde tech n ique to the lization an d position of th e n ails is satisfactory, th e
level of the olecranon to secu re in cision s over th e d istal en tran ce sites are closed
rigid stabilization ( Fig 4 .6 -4 ). w ith sim ple su tu res ( Fig 4 .6 -5 ).

Fig 4 .6 -4 a – b AP an d latera l
x-rays taken im m ed iately
postoperative. Th e tip of th e
n a il on th e rad iu s lies at th e
level of th e rad ia l tu berosity
a n d th at of th e u ln ar n a il lies
at th e level of th e coron oid
process. Note th at th e tips of
th e n ails are d irected toward
each oth er w h ich en h an ces
separation of th e in terosse- Fig 4 .6 -5 Sk in closu re. Th e in cision s over th e
ou s m em bran e. en tran ce site are closed w ith sim ple su tu res.

10 0
 4 .6 Ra d ia l a n d u ln a r s h a ft re fra ct u re a ft e r co n s e r va t ive t re a t m e n t (2 2 -D/ 4 .1)

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

If adequ ate stabilization is ach ieved, th e patien t is allowed to begin m otion of th e forearm
as relief of th e operative pain perm its. X-rays are taken at 4 weeks ( Fig 4 .6 -6 ) an d 3 m on th s
( Fig 4 .6 -7 ). Nail rem oval can be accom plish ed wh en fu ll h ealin g an d rem odelin g of th e
fractu re h as been ach ieved.

AP an d lateral x-rays taken

Fig 4 .6 -6 a – b Fig 4 .6 -7a – b3-m on th follow-u p x-rays de -
4 weeks postoperatively dem on strate early m on strate com plete h ealin g an d rem ode-
callu s an d m ain ten an ce of th e origin al lin g of th e fractu re sites. Th e n ails can be
redu ction . safely rem oved at th is tim e.

101
 4 Fo re a rm

10 2
4.7 Distal radial and ulnar diaphyse al-m e taphyse al fracture s,
displace d (22-D/ 4.1)
1 Ca s e d e s crip t io n

A 13-year-old m ale w h o h ad su stain ed severe h ead trau m a as

a resu lt of an acciden t between a m otor veh icle an d a bicycle;
h e also h ad a d isplaced fractu re of th e distal radiu s at th e tran -
sition zon e between th e m etaph ysis an d d iaph ysis ( Fig 4 .7-1).
Th e fractu re site was too proxim al from th e d istal en d to u se
typical K-w ire xation .

AP an d lateral x-rays dem on stratin g tran sverse

Fig 4 .7-1a – b
fractu res of both th e radiu s an d u ln a at th e diaph yseal–
m etaphyseal ju n ction .

2 Su rgica l a p p ro a ch

Ra d ia l in s e r t io n
Th e sk in is tran sversely in cised posteriorly over th e pal-
pable rad ial tu bercle as described in th e case presen ted in
Fig 4 .3 -3 in ch apter 4.3 Forearm sh aft fractu re, tran sverse.
Th e ten don com partm en ts are open ed to ex pose th e bon e.
Th e aw l is placed posterom ed ial to th e tu bercle an d d rilled
alm ost per pen dicu lar to th e cortex to en ter th e m edu llary
can al d irectly. Next, th e n ail is in serted an d gu ided in su ch a
way th at it con tacts th e opposite cortex before it reach es th e Fig 4 .7-2 Th e rad ial en try
fractu re site ( Fig 4 .7-2 ). To facilitate n ail advan cem en t in th is poin t is created d istally in th e
m an n er, th e tip m ay n eed to h ave a greater ben d. Becau se posterior cortex of th e palpable
of th e degree of cu r vatu re requ ired, advan cem en t of th e n ail rad ial tu bercle u sin g an aw l.
m ay be d if cu lt. Th e n ail n eeds to be advan ced slow ly an d Th e aw l is gradu ally d irected
carefu lly. It is advisable to avoid u sin g a h am m er as it m ay 45° as it drills th rou gh th e cor-
blow ou t a fragm en t. tex (cu r ved arrow).

10 3
 4 Fo re a rm

2 Su rgica l a p p ro a ch (co n t)

Uln a r in s e r t io n
In th e u ln a, th e sk in is in cised prox im ally on th e lateral
aspect of th e olecran on 3 cm d istal to th e tip of th e apoph ysis. Fig 4 .7-3 Th e en tran ce
Th e aw l is u sed to create th e en tran ce site by rst in sertin g site is m ade in th e lateral
it per pen d icu larly to th e lateral cortex an d th en d irectin g it cortex of th e prox im al
d istally as it is drilled th rou gh th e cortex ( Fig 4 .7-3 ). Th e n ail u ln a. Th e aw l is gradu -
is in serted an d advan ced to th e fractu re site in a an tegrade ally d irected 45° as it is
m an n er as described in th e case presen ted in Figs 4 .3 -5 to drilled th rou gh th e cor-
4 .3 -7 in ch apter 4.3 Forearm sh aft fractu res, tran sverse. tex (cu r ved arrow).

3 Re d u ct io n a n d fixa t io n

Ra d ia l re d u ct io n Prior to its n al in sertion , th e n ail is sign i can tly preben t in

First, th e n ail is advan ced prox im ally to th e fractu re site. At its d istal portion at th at pred icted level w h ich w ill lie at th e
th e sam e tim e th e n ail in th e u ln a is advan ced d istally to its fractu re site ( Fig 4 .7-5 a ). Th e n ail is th en advan ced to place
fractu re site ( Fig 4 .7-4 ). Th is allow s th e n ails to be u tilized, th e preben t portion exactly at th e fractu re site. On ce it is fu lly
if n ecessar y, as lever arm s to facilitate m an ipu lation of th e in serted, th e n ail is rotated to place th e apex of th e ben d in
fragm en ts. Th e radiu s is in directly redu ced extern ally by th e plan e of m ax im u m m alalign m en t ( Fig 4 .7-5 b ). Th is sh ou ld
m an ipu latin g th e lon ger prox im al fragm en t by h an d wh ile provide a satisfactory lin ear align m en t of th e fractu re frag-
sim u ltan eou sly m an ipu latin g th e d istal fragm en t w ith th e m en ts. Th e n ail is cu t an d th e en d placed in th e su bcu tan eou s
n ail. Wh en su f cien t apposition of th e fractu re su rfaces h as tissu e followed by closu re of th e in cision .
been ach ieved, th e n ail is advan ced in to th e proxim al frag-
m en t. Uln a r re d u ct io n
Th e distal u ln a is easy to stabilize w ith an tegrade n ailin g. Th e
Align m e n t co rre ct io n sh ort d istal fragm en t h as a n arrow m edu llary can al wh ich
Often th e n ail w ill n ot cau se th e d istal fragm en t to align accu - provides good in tern al stability for th e n ail. On ce both n ails
rately. Th e d istal rad iu s ten ds to d rift in to a valgu s position . To are in th eir n al position th ere sh ou ld be a satisfactory lin ear
correct th is, th e su rgeon n eeds to assess th e poin t on th e n ail an d rotation al align m en t of th e fractu re fragm en ts ( Fig 4 .7-6 ).
wh ich w ill lie at th e fractu re site wh en it is n ally im plan ted.

10 4
 4 .7 Dis t a l ra d ia l a n d u ln a r d ia p h ys e a l-m e t a p h ys e a l fra ct u re s , d is p la ce d (2 2 -D/ 4 .1)

3 Re d u ct io n a n d fixa t io n (co n t)

a b

Fig 4 .7-4 In itial n ail passag- Fig 4 .7-5 a – b Align m en t correction .

es. After creatin g their respec- a Th e rad ial n ail is ben t d istally at th e b In its n al position , th e apex of th e ben d
tive entrance sites, the n ails area predeterm in ed to lie at th e fractu re (arrow) h as been rotated at th e fractu re
are advanced to their respec- site. Th e ben d is created so as to resist site so th at it forces th e d istal fragm en t
tive fractu re sites. th e ten den cy of th e fractu re to d rift in to in to satisfactory align m en t.
valgu s m alalign m en t.

Fig 4 .7-6 a – c
a Fin al position of th e in serted n ails.
b–c AP an d lateral x-rays taken postoperatively dem on strat-
in g a satisfactor y redu ction of th e fractu re fragm en ts.
Note also, th e apex of th e secon dary ben d of th e rad ial
a
n ail (arrow) is at th e fractu re site.

10 5
 4 Fo re a rm

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Th e postoperative m an agem en t ( Fig 4 .7-7 ) is th e sam e as for

th e oth er forearm sh aft fractu res treated by th e ESIN tech -
n iqu e. Sin ce an addition al cast is n ot in dicated, m otion can
be in itiated as soon as th e patien t can tolerate it. If th e stabil-
ity of th e in tram edu llary xation seem s to be in adequ ate to
gu aran tee align m en t of th e fractu re fragm en ts, th en th e ESIN
tech n iqu e is n ot appropriate an d th e fractu re sh ou ld be stabi-
lized by an oth er m eth od su ch as a sm all extern al xator.

Fig 4 .7-7a – bFin al h ealin g prior to n ail rem oval. AP an d lat-

eral x-rays. Th e in itial redu ction h as been m ain tain ed an d
th ere is good rem odelin g of th e fractu re callu s.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Fig 4 .7-8 Too m u ch obliqu ity in in sert- In trodu ce th e rad ial n ail alm ost per pen d icu lar
in g th e rad ial n ail cau ses th e n ail to pass to th e cortex. If th e lateral in sertion site produ ces too
th e fractu re site before it con tacts th e obliqu e an an gle, ch an ge to a posterior in sertion
opposite cortex of th e d istal fragm en t. site. Th e sam e is tru e if th e posterior site is too obliqu e.
Th is does n ot allow su f cien t stability to
m ain tain th e align m en t of th e fractu re
fragm en ts.

If a h am m er is u sed to advan ce th e n ail in th e th in Never u se th e h am m er at th ese poin ts of in sertion .

m etaph yseal segm en t, th ere is th e dan ger th at it w ill blow If a fragm en t is blow n ou t, th ere is alm ost n o ch an ce
ou t a fragm en t. of obtain in g a stable redu ction w ith th is tech n iqu e.
Stabilization of th e fractu re m ay requ ire con vertin g to
th e u se of an extern al fixator.

10 6
 4 .7 Dis t a l ra d ia l a n d u ln a r d ia p h ys e a l-m e t a p h ys e a l fra ct u re s , d is p la ce d (2 2 -D/ 4 .1)

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Ap p ro a ch (co n t) Ap p ro a ch (co n t)
In th ose cases wh ere it is n ot possible to obtain a An tegrade n ailin g of th e radiu s is a problem atic solu tion
stable redu ction w ith retrograde xation , it m u st be for th is situ ation . It is better to u se an extern al fixator
rem em bered th at an tegrade radial n ailin g risks ( Fig 4 .7-10 ).
in ju ry to th e deep bran ch of th e rad ial n erve ( Fig 4 .7-9 ).

Fig 4 .7-10 a – e
a Displaced distal m eta-
d iaph yseal forearm
fractu re, too close to th e
ph ysis to u se ESIN for
a
th e rad iu s, to far from
th e ph ysis to u se K-
Fig 4 .7-9 a – c Avoid prox im al rad ial in sertion .
w ires.
a Th is lin e draw in g dem on strates th e proxim ity of th e
b – c Decision for a xation of
rad ial n erve to a proxim al in sertion site in th e rad iu s.
th e rad iu s w ith a sm all
b – c AP an d lateral x-rays of a patien t w h o h ad th e rad ial
extern al xator an d
n ail in serted proxim ally. Th e fractu res h ave h ealed
ESIN stabilization of th e
bu t th ere was a profou n d rad ial n erve paralysis.
u ln a. Th e postopera-
tive x-ray sh ow s a good
align m en t.
d – e After 4 weeks, th e exter-
n al xator was rem oved
w ith ou t an y an esth esia.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Failu re to fu lly evalu ate th e n al an atom ical align m en t Carefu l evalu ation an d con trol of th e n ail is always
at th e fractu re site m ay resu lt in an u n satisfactory align - ver y im portan t in all th e stages of m an agin g th ese
m en t of th e d istal fragm en t. m etaph yseal-diaphyseal fractu res. If n eeded, th e rad ial
n ail sh ou ld be w ith draw n an d its cu r vatu re accen tu ated.
Th e n ail m u st th en be replaced or exch an ged.

10 7
 5 Fe m ur

5 .1 In t ro d u ct io n —fe m o ra l fra ct u re s 10 9
1 In d ica tio n 10 9
2 Pa tie n t p re p a ra tio n a n d p o sitio n in g 10 9
3 Su rgica l p rin cip le s 111
4 Im p la n t re m o va l 111
5 Su gge ste d re a d in g 112

5 .2 Pro xim a l fe m o ra l fra ct u re , s u b t ro ch a n t e ric

(32-D/ 5 .1) 113

5 .3 Fe m o ra l s h a ft fra ct u re , t ra n s ve rs e (32 -D/ 4 .1) 119

5 .4 Fe m o ra l s h a ft re fra ct u re , o b liq u e (32 -D/ 5 .1) 12 9

5 .5 Se gm e n t a l fe m o ra l s h a ft fra ct u re (32 -D/ 5 .2) a n d

ip s ila t e ra l t ib ia l s h a ft fra ct u re (42 -D/ 5 .1) 135

5 .6 Dis t a l fe m o ra l fra ct u re (33 -M/ 3 .1) 141

10 8
5.1 Introduction —fe m oral fracture s

1 In d ica t io n

No n o p e ra t ive t re a t m e n t in t h e yo u n ge r p a t ie n t Ad va n t a ge s o f ESIN
Becau se h ealin g is rapid, n on operative tech n iqu es su ch as As ou tlin ed in ch apter 1 Basic prin ciples dealin g w ith th e
h ip spica casts w ith or w ith ou t prelim in ar y traction are th e basics prin ciples of ESIN, th is tech n iqu e stabilizes th e frac-
preferred m an agem en t in th e 1–3 year age grou p. An oth er tu re u tilizin g a m in im ally in vasive tech n iqu e. In m ost cases
reason th at con ser vative m an agem en t is recom m en ded in stability is su f cien t to allow early m otion an d protected
th ese you n ger patien ts is th e su spected risk of overgrow th weigh t bearin g. Th is in tu rn decreases th e tim e n eeded to
w ith ESIN. Sin ce very little ex perien ce h as been gain ed w ith ach ieve a fu ll retu rn to n orm al fu n ction .
ESIN in th is ver y you n g age grou p, th e exten t of possible com -
plication s h as n ot been determ in ed.

Su rge r y—a ge d e p e n d e n t
Th e m ost com m on ly accepted in d ication for operative in ter-
ven tion of fem oral sh aft fractu res is for th e 3 –15 year age
grou p. Th e decision to u tilize th e ESIN tech n iqu e is based
u pon m an y factors. Th ese m ay in clu de th e presen ce of oth er
in ju ries or h ealth con d ition s or th e size an d age of th e patien t.
Th e ex perien ce of th e su rgeon can also be a factor in th e deci-
sion m ak in g.

2 Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Pa t ie n t p re p a ra t io n Pa t ie n t p o s it io n in g
Th ese patien ts n eed to be both h em odyn am ically an d n eu ro- ESIN in patien ts w ith fem oral fractu res is perform ed w ith
logically stable prior to th eir su rgical procedu res. In certain th e patien t lyin g su pin e eith er on a stan dard fractu re table
situ ation s w h ere th e fractu res are open or th ere is n eu rovas- or su spen ded in traction on th e ped iatric orth oped ic table
cu lar com prom ise, th e su rgical procedu re m ay n eed to be depen d in g u pon th e experien ce an d preferen ce of th e treatin g
perform ed u n der em ergen cy or u rgen t con d ition s. su rgeon . Th e u se of th e orth oped ic table m ay greatly facilitate
th e in sertion of th e n ails in th ose in stan ces wh ere m in im al
Me d ica t io n su rgical assistan ce is available, in ch ild ren wh ose fractu res
Th e protocol regard in g th e u se of proph ylactic an tibiotics is are tran sverse, or in th e larger older ch ild.
based u pon th e stan dard of care in th e clin ic protocol. Like-
w ise, th e stan dard gu idelin es sh ou ld also be followed regard-
in g th e u se of th rom bosis proph ylax is in fem ales wh o are
postm en arch al, patien ts w ith pelvic trau m a, or th ose patien ts
wh o are over weigh t.

10 9
 5 Fe m u r

2 Pa t ie n t p re p a ra t io n a n d p o s it io n in g (co n t )

Th e proper position of th e patien t on th e stan dard operatin g patien t in traction on th e pediatric orth oped ic table is seen in
table alon g w ith th e position in g of th e in tact lower extrem - Fig 5 .1-2 .
ity is dem on strated in Fig 5 .1-1 . Th e altern ative position of th e

a b c

Fig 5 .1-1a – c Position in g on a stan dard b Clin ical ph oto dem on stratin g th e po - c Th e sh eet is attach ed to th e side of th e
table. sition of th e patien t. A folded sh eet is table w ith a large su rgical clam p.
a Position of th e patien t on th e placed arou n d th e proxim al portion
stan dard operatin g table. of th e extrem ity in volved to provide
cou n tertraction .

a b

Fig 5 .1-2 a -b Position in g an a traction table.

a Patien t su spen ded in traction on an orth oped ic table. Th e u n in ju red lower
extrem ity sh ou ld be at th e sam e level as th e in ju red extrem ity u n less th ere is n o
oth er way to obtain adequ ate im agin g.
b Clin ical ph oto of a patien t on th e traction table.

110
 5 .1 In t ro d u ct io n —fe m o ra l fra ct u re s

2 Pa t ie n t p re p a ra t io n a n d p o s it io n in g (co n t )

Pre p a ra t io n fo r t h e s u rgica l p ro ce d u re Eq u ip m e n t
Prior to perform in g th e su rgical tech n iqu e, certain preop- In add ition to th e stan dard su rgical in stru m en ts u sed to treat
erative preparation s are n eeded regard in g th e equ ipm en t any lon g-bon e fractu re, th e m in im al requ irem en ts to m an age
requ ired. Decision s also n eed to be m ade regard in g th e selec- fem oral fractu res w ith th e ESIN tech n iqu e in clu de:
tion of th e appropriate n ails an d th e su rgical approach es. Stan dard ESIN set.
Nails:
Th e fractu re pattern determ in es th e direction of n ailin g, 2.0 –5.0 m m d iam eter stain less steel or titan iu m ; th e selected
wh ich , in tu rn , determ in es th e position in g of th e patien t an d n ails sh ou ld be 33% (1/ 3) of th e d iam eter of th e in tram ed-
th e im age in ten si er prior to th e actu al procedu re. It w ill also u llar y can al.
determ in e th e location of th e prim ary su rgical in cision . For Im age in ten si er.
an tegrade n ailin g th e n ail is in serted in to th e su btroch an teric
area. For retrograde n ailin g th e n ail is in serted in to th e distal
part of th e femu r.

3 Su rgica l p rin cip le s 4 Im p la n t re m o va l

In d iscu ssin g th e su rgical m an agem en t of fem oral fractu res Tim in g o f re m o va l

in ch ild ren , th ey w ill be d ivided in to th e follow in g su bgrou ps X-rays are taken ju st prior to n ail rem oval. Depen d in g on age,
based u pon location an d type of fractu re pattern : fractu re type an d site, an d th e level of recovery, th is period
can ran ge from 6 –12 m on th s (exeption ally, 4 m on th s m ay
Th e speci c su rgical tech n iqu es for all su btypes (location an d su f ce) follow in g su rger y.
fractu re pattern) of fem oral fractu res in ch ildren w ill be dis-
cu ssed in th eir respective su bch apters to follow : Ext ra ct io n t e ch n iq u e s
5.2 Su btroch an ter ic fractu res Th e old in cision site is u tilized to ex pose th e n ail en d. After
5.3 Tran sverse an d spiral sh aft fractu res rst rem ovin g th e cap (if plastic caps or en d caps were u sed),
5.4 Refractu re follow in g application of an extern al xator lock in g pliers are u sed to grasp th e en d of th e n ail. Th e n ail is
5.5 Segm en tal an d ipsilateral fractu res (polytrau m a) th en carefu lly rem oved. Som etim es th e n ail en d is position ed
too close to th e bon e to allow th e extraction tool to obtain
a secu re grasp. If th is is th e case, th e n ail en d is sim ply ben t
su f cien tly away from th e cortex to perm it safe extraction .

If th e n ail appears to resist extraction , occasion ally graspin g

it w ith th e T-h an d le in serter an d rotatin g th e n ail w ill loosen
it su f cien tly to facilitate th e procedu re.

111
 5 Fe m u r

5 Su gge s t e d re a d in g

Bar- On E, Sagiv S, Po rat S (1997) Ligie r J N , Me t aize au J P, P re vo t J, e t al (1988)

Extern al xation or exible in tram edu llary n ailin g for fem o- Elastic stable in tram edu llary n ailin g of fem oral sh aft frac-
ral sh aft fractu res in ch ild ren . tu res in ch ild ren . J Bone Joint Surg Br; 70(1):74 –77.
J Bone Joint Surg. [Br]; 79-B: 975 –978. Mau re r G, Parsch K (2000)
Care y TP, Galp in R D (1996) Su rgical Treatm en t of Pediatric Fem oral Sh aft Fractu res.
Flex ible in tram edu llary n ail xation of ped iatric fem oral frac- Techniques in Orthopaedics; 15(1):67–78.
tu res. Me t aize au J P (2004)
Clin Orthop; 332:110 –118. Stable elastic in tram edu llary n ailin g for fractu res of th e
D ie t z HG, Sch m it t e n be ch e r PP, Illin g P (1996) fem u r in ch ildren .
Die in tram edu lläre Osteosyn th ese im Wach stu m salter. J Bone Joint Surg Br; 86(7):954 –957.
Urban & München-Wien-Baltimore: Schwarzenberg. N arayan an UG, Hy m a n J E, Wainw righ t A M , e t
D ie t z HG, Jo p p ich I, Marzi I, e t al (2001) al (2004)
[ Treatm en t of fem oral fractu res in ch ild h ood. Con sen su s Com plication s of elastic stable in tram edu llary n ail xation
Report of th e 19th Meetin g of th e Ch ild Trau m atology of ped iatric fem oral fractu res, an d h ow to avoid th em .
Section of th e DGU, Mu n ich , 23 –24 Ju n e 2000.] J Pediatr Orthop; 24(4):363 –369.
Unfallchirurg; 104(8):788 –790. Parsch K D (1997)
He d in H (2004) Modern tren ds in in tern al xation of fem oral sh aft fractu res
Su rgical treatm en t of fem oral fractu res in ch ildren . in ch ild ren . A critical review.
Com parison between extern al xation an d elastic in tram ed- J Pediatr Orthop B; 6(2):117–125.
u llar y n ails: a review. Sch m it t e n be ch e r PP, D ie t z HG (1996)
Acta Orthop Scand; 75(3):231–24 0. Elastic stable in tram edu llary n ailin g of fem oral sh aft
He y w o rt h BE, Galan o GJ, Vit ale M A , e t al (200 4) fractu res in ch ildren (“Nan cy-Nailin g”).
Man agem en t of closed fem oral sh aft fractu res in ch ildren , Orthopaedics and Traumatology; 4201–4210.
ages 6 to 10: n ation al practice pattern s an d em ergin g tren ds. Sch m it t e n be ch e r PP, D ie t z HG, Lin h art WE, e t
J Pediatr Orthop; 24(5):455 –459. al (2000)
Ho u sh ian S, Go t h ge n CB, Pe d e rse n N W, e t al (2004) Com plication s an d problem s in in tram edu llary n ailin g of
Fem oral sh aft fractu res in ch ild ren : elastic stable in tram ed- ch ild ren ’s fractu res.
u llary n ailin g in 31 cases. Eur J Trauma; 26(6):287–293.
Acta Orthop Scand;75(3):249 –251. Till H , Hu t t l B, K n o rr P, e t al (2000)
Ju be l A , A n d e rm ah r J, P ro ko p A , e t al (2004) Elastic stable in tram edu llary n ailin g (ESIN) provides good
[ Pitfalls an d com plication s of elastic stable in tram edu llar y lon g-term resu lts in ped iatric lon g-bon e fractu res.
n ailin g (ESIN) of fem oral fractu res in in fan cy.] Eur J Pediatr Surg; 10(5):319 –322.
Unfallchirurg; 107(9):74 4 –749.

112
5.2 Proxim al fe m oral fracture , subtrochante ric (32-D/ 5.1)

1 Ca s e d e s crip t io n

An 8-year-old boy su stain ed an in ju r y to h is left lower extrem ity wh ile

sn ow board in g. He presen ted w ith a m arked ly swollen left th igh . Clin ical-
ly, th is appeared to be h is on ly in ju r y. Distal n eu rovascu lar fu n ction was
in tact. X-rays taken in th e em ergen cy room revealed a d isplaced su btro-
ch an teric fractu re of th e left fem u r ( Fig 5 .2 -1). It was felt th at th is fractu re
cou ld easily be m an aged by th e ESIN tech n iqu e an d th e patien t was pre-
pared for su rger y.

Th e preoperative x-ray sh ow s a h igh su btroch an teric fractu re.

Fig 5 .2 -1
A secon d x-ray is n ot n eeded in th is case. Add ition al pain for th e ch ild can
be avoided.

2 Su rgica l a p p ro a ch

After th e left extrem ity h as been su rgically prepped an d

d raped, bilateral sym m etrical sk in in cision s are m ade
( Fig 5 .2 -2 ). Th e d istal sk in lan d m ark is th e u pper pole of th e
patella. Th e skin an d the fascia are incised together. Blu nt dis-
section is then continued th rou gh th e m u scle to th e bon e.
Im portan t: en su re th at th e en tran ce poin ts are ou tside th e
join t capsu le an d away from th e edge of th e ph ysis.

2–3 cm

Fig 5 .2 -2Sk in in cision s.

Sym m etrical m edial an d lateral sk in in cision s start at th e
su perior pole of th e patella an d progress 2 –3 cm prox im ally.

113
 5 Fe m u r

2 Su rgica l a p p ro a ch (co n t)

En t ra n ce s it e s
Th e en try sites are rst perforated by an aw l in th e m ost
Fig 5 .2 -3 Awl placem en t.
prox im al en d of th e in cision (2–3 cm in progress of th e u pper
Th e awl is rst placed per-
pole of th e patella). Th e awl is in itially placed 90 º to th e cortex
pen dicu lar to th e cortex an d
to keep it from slippin g off. On ce th e aw l is rm ly seated on
rotated u n til it is well seated
th e su rface of th e cortex, it is redu ced to an an gle of 45º to th e
in th e bon e. At th is poin t it
sh aft axis an d th e perforation of th e bon e is con tinu ed at an
is an gu lated 45° to th e sh aft
u pward an gle ( Fig 5 .2 -3 ). If th e cortex is very h ard, a drill m ay
axis an d advan ced in order
be n ecessary to carefu lly pen etrate it.
to produ ce a ch an n el in th e
cortex.
Na il s e le ct io n
Determ in e th e correct d iam eter of th e n ail by m easu rin g Na il in s e r t io n
th e isth m u s of th e m edu llary cavity on th e x-ray im age. Th e Carefu lly in sert th e n ail in to th e m edu llar y can al by h an d or
d iam eter of th e n ail sh ou ld be 1/ 3 of th e m edu llar y cavity at u sin g th e T-h an dle in serter ( Fig 5.2-4 ). Follow in g its in sertion ,
its n arrowest poin t. Select iden tical n ails. Usin g n ails of d if- th e position of th e n ail is con rm ed w ith th e im age in ten si-
feren t d iam eters can produ ce varu s or valgu s m alalign m en t. er. Note th at th e cu r ve of th e tip is accen tu ated to facilitate
its bou n cin g off th e opposite cortex. Carefu lly advan ce th e
rst n ail u p to th e fractu re zon e.

Follow in g th is, th e secon d n ail is in serted in to its en tran ce

site an d advan ced to th e fractu re zon e ( Fig 5.2-5 ).

3 Re d u ct io n a n d fixa t io n

Fra ct u re re d u ct io n Fin a l p o s it io n in g
At th e fractu re site, on e of th e n ails is u su ally m an ipu lated in On ce th e n ail tips are in th eir n al position , th e en d of each n ail
su ch a m an n er th at its tip redu ces th e fragm en ts ( Fig 5.2-6 ). is cu t, leavin g 1–2 cm protru d in g from th e cortex ( Fig 5.2-9 b ).
On ce th e redu ction h as been accom plish ed, both n ails are Th e am ou n t left protru d in g is depen den t u pon th e am ou n t of
advan ced in to th e proxim al fragm en t. In th is case, th e m ed ial soft-tissu e coverage arou n d th e tips. After cu ttin g to th e n al
n ail sh ou ld be d irected to th e fem oral n eck an d th e lateral len gth , caps can be placed over th e protru d in g en ds of th e
n ail toward th e greater troch an ter. Ju st prior to advan cin g to n ails to protect th e soft tissu es ( Fig 5.2-9 a).
th eir n al position , th e n ails are cu t leavin g en ou gh len gth to
m an ipu late an d advan ce th em to th eir n al position ( Fig 5.2-7 ). Ve r y p ro xim a l p o s it io n
On ce both n ails h ave en tered th e prox im al fragm en t th ey are In th e n al redu ction , th e tips sh ou ld be align ed so th at th e
th en tapped toward th eir n al position ( Fig 5.2-8 ). lateral n ail tip is d irected toward th e greater troch an ter an d
th e m ed ial n ail tip is placed in th e fem oral n eck alm ost u p to
th e ph yseal plate. It n eeds to be em ph asized h ere th at n ails
stabilizin g su btroch an ter ic fractu res are passed as prox im al as
possible in to th e in tertroch an ter ic region to provide en h an ced
stability. Passin g th e n ails prox im ally to th is degree is n ot
n ecessar y to stabilize m idsh aft fractu res.

114
 5 .2 Pro xim a l fe m o ra l fra ct u re , s u b t ro ch a n t e ric (32 -D/ 5 .1)

3 Re d u ct io n a n d fixa t io n (co n t)

18 0 °

Fig 5 .2 -4 In sertion of rst n ail. Fig 5 .2 -5 In sertion of secon d n ail. Fig 5 .2 -6 Fractu re redu ction .
Th e rst n ail is in serted in to th e m ed- On ce th e rst n ail h as been advan ced Th e tip of on e of th e n ails is m an ipu -
u llar y cavity an d advan ced prox im ally. to th e fractu re site, th e secon d n ail is lated to en ter th e m edu llary can al of th e
Th e ben d in th e tip m ay n eed to be in serted an d also advan ced prox im ally. proxim al fragm en t. It is rotated (circu lar
in creased sligh tly to facilitate its ad- arrow) so as to im prove th e redu ction .
van cin g past th e opposite cortex.

115
 5 Fe m u r

3 Re d u ct io n a n d fixa t io n (co n t)

18 0 °
a b

Fig 5 .2 -7Prox im al advan cem en t. Fig 5 .2 -8 Fin al seatin g. Fig 5 .2 -9 a – bNail protection .
Both n ails are advan ced in to th e proxi- On ce th e correct d irection an d posi- Plastic caps or en d caps are placed over
m al fragm en t w ith on e d irected in to th e tion h ave been establish ed, th e n ails are th e cu t en d. Th e wou n d is closed.
fem oral n eck an d th e oth er toward th e tapped in to th eir n al position (dotted
greater troch an ter. A prelim in ary cu t lin es). On e tip lies w ith in th e greater
is m ade, leavin g en ou gh len gth for th e troch an ter, wh ile th e oth er lies ju st
n al advan cem en t. d istal to th e capital ph ysis.

116
 5 .2 Pro xim a l fe m o ra l fra ct u re , s u b t ro ch a n t e ric (32 -D/ 5 .1)

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Postoperatively, th e ch ild is allowed as

much m otion of th e extrem ity as tolerat-
ed. Th ey are u su ally m obilized w ith ou t
cru tch es. Th e rst x-rays are taken in th e
ou tpatien t clin ic at 4 weeks ( Fig 5 .2 -10 ).
If th ere is su f cien t callu s, fu ll weight
bearin g can begin . Usu ally th ere is su f-
cien t h ealin g by 8 m on th s to con sider
rem oval of th e n ails ( Fig 5 .2-11).

a b a b

Fig 5.2-10a – bAP and lateral x-rays taken AP an d lateral x-rays

Fig 5 .2 -11a – b
4 weeks after ESIN demon strate su f cient taken 8 m on th s after ESIN dem on strate
healing to allow fu ll weight bearing. su f cien t con solidation to perm it n ail
rem oval.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Makin g th e in cision too proxim al. Th e en tran ce sites n eed to be at a su f cien t d istan ce
from th e fractu re site, to en su re th at th e fractu re site is
Th e ph ysis is in ju red by too d istal in sertion of th e n ail. n ot en tered or violated an d rem ain s closed.

Th e en tran ce poin ts are n ot on th e sam e level.

117
 5 Fe m u r

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n —s p e cia l ca s e
Perforation of th e prox im al cortex du rin g in sertion . A 14-year-old m ale was stru ck by a car, su stain in g a su b-
troch an teric fractu re of h is righ t fem u r. 3 m on th s earlier,
Corkscrew ph en om en on w ith m ore th an two n ail h e h ad u n dergon e bilateral in situ screw xation as treat-
ju n ction s. m en t for a slipped capital fem oral epiph ysis. Th e fractu re
occu rred at th e level of th e screw h ead ( Fig 5 .2 -14 ).

Prior to th e developm en t of th e ESIN tech n iqu e, treat-

m en t of su ch a fractu re wou ld h ave m ost likely requ ired
an open procedu re an d th e u se of a large plate an d/or h ip
screw. Th is fractu re was easily stabilized by passin g th e
exible n ails retrograde arou n d th e screw ( Fig 5 .2 -14 ).

Fig 5 .2 -12 a – b Crossin g

th e n ails at th e fractu re
site in stead of h avin g th e
m axim u m separation in th is
a b
area.
a b c

Fig 5 .2 -14 a – c
a Th e fractu re appears to origin ate in th e su b-
troch an teric area wh ere th e screw en tered th e lateral
cortex.
b – c AP an d lateral x-rays sh ow th e n ails passin g arou n d
th e screw to be secu red in th e prox im al femu r. Th ere
a b
is early callu s form ation .
Fig 5 .2 -13 a – b Leavin g th e n a ils too lon g cau ses th e en ds to
irr itate th e sk in en ou gh to pred ispose it to perforation a n d a Re h a b ilit a tio n
su bsequ en t in fection . Im m ed iate m obilization was in itiated on
cru tch es. Th e patien t progressed to fu ll
weigh t bearin g at 4 weeks by wh ich tim e
x-rays revealed good callu s form ation .

Fig 5 .2 -15 Th e screw was rem oved 1 year

after th e acciden t. X-rays 6 m on th s after
rem oval of th e screw dem on strate th at
th ere is su f cien t h ealin g of th e fractu re to
con sider n ail rem oval.

118
5.3 Fe m oral shaft fracture , transve rse (32-D/ 4.1)

1 Ca s e d e s crip t io n

Ge n e ra l co n s id e ra t io n
Th e m an agem en t of oblique an d tran sverse fractu re pattern s
of th e fem oral sh aft u sin g the ESIN tech n iqu e is essen tially th e
sam e. The follow in g case describes th e m an agem en t of a tran s-
verse fem oral m idsh aft fractu re. An altern ative case w ith a spi-
ral fem oral sh aft fractu re is presen ted later on in th is ch apter.

Ca s e 32-D/ 4 .1
A 10-year-old boy fell off h is bicycle an d presen ted w ith a m ark-
edly swollen an d pain fu l righ t th igh . X-rays taken in the em er-
gen cy room revealed a tran sverse m idsh aft fractu re of th e righ t
femu r ( Fig 5 .3 -1). The fractu re was closed and presen ted as an
isolated in ju ry. There were no neu rovascu lar com plication s.

Fig 5 .3 -1a – b AP an d lateral x-rays sh ow in g tran sverse

m idsh aft fractu re of th e righ t fem u r. Th ere was sign i can t
a b
sh orten in g bu t m in im al an gu lation .

2 Su rgica l a p p ro a ch

Sk in in cis io n s
After th e extrem ity h as been su rgically prepped an d draped,
bilateral sym m etrical sk in in cision s are m ade ( Fig 5.3 -2 ). Th e
d istal sk in lan d m ark is th e u pper pole of th e patella. Th e sk in
an d th e fascia are in cised togeth er. Blu n t d issection is th en
con tin u ed th rou gh th e m u scle to th e bon e. Im portan t: en -
su re th at th e en tran ce poin ts are ou tside th e join t capsu le an d
away from th e edge of th e physis.

2–3 cm

Fig 5 .3 -2Skin in cision s.

Sym m etrical m edial an d lateral sk in in cision s start at th e
su perior pole of th e patella an d progress prox im ally 2 –3 cm .

119
 5 Fe m u r

2 Su rgica l a p p ro a ch (co n t)

En t ra n ce s it e Na il in s e r t io n
Th e cor tex is rst per forated by a n aw l. It is in it ia lly placed Carefu lly in sert th e n ail in to th e m edu llary can al by h an d
90 ° to t h e cor tex to keep it from slippin g off. On ce th e aw l or u sin g th e T-h an dle in serter( Fig 5 .3 -4 ). In itially, it is often
is r m ly seated on t h e su r face of th e cor tex , it is a n gled so easiest to in sert th e n ail tip by h an d. After its in sertion , th e
th at th e en tra n ce ch a n n el is 45° to th e cor tex ( Fig 5 .3 -3 ). If position of th e n ail is con rm ed w ith th e im age in ten si er.
th e cor tex is ver y h ard, a d r ill m ay be n ecessar y to ca refu lly
pen etrate th e cor tex.

Na il s e le ct io n
Determ in e th e correct d iam eter of th e n ail by m easu rin g th e
isth mu s of th e m edu llary can al on th e x-ray im age. Th e d iam -
eter of th e n ail sh ou ld be 1/ 3 of th e m edu llar y can al at its
n arrowest poin t. Select iden tical n ails. Usin g n ails of differen t
d iam eters can produ ce varu s or valgu s m alalign m en t. A sm all
extra ben d is m ade at th e tip to facilitate its bou n cin g off th e
opposite cortex.

4 5°

Fig 5 .3 -3 Placem en t of th e awl. Fig 5 .3 -4 First n ail.

Th e awl is rst placed per pen d icu lar to th e cortex an d rotated Th e tip of th e precon tou red n ail is in serted rst in to th e m ed-
u n til it is well seated in th e bon e. At th is poin t it is th en an gu - u llary can al an d advan ced proxim ally. To facilitate its m ak in g
lated 45° to th e sh aft ax is to produ ce an obliqu e ch an n el in th e rst tu rn again st th e opposite in n er cortex, a sligh t cu r ve
th e cortex. is in itially placed in th e n ail ju st prox im al to th e tip.

12 0
 5 .3 Fe m o ra l s h a ft fra ct u re , t ra n s ve rs e (3 2 -D/ 4 .1)

2 Su rgica l a p p ro a ch (co n t) 3 Re d u ct io n a n d fixa t io n

Carefu lly advan ce th e rst n ail toward th e fractu re zon e. Fra ct u re re d u ct io n

Follow in g th is, th e secon d n ail is in serted an d advan ced to th e At th e fractu re site, on e of th e n ails is u su ally m an ipu lated
fractu re zon e ( Fig 5 .3 -5 ). Th e order in w h ich th e n ail is passed in su ch a m an n er th at its tip redu ces th e fragm en ts. On ce th e
depen ds u pon wh ich on e passes m ore easily. redu ction h as been accom plish ed, both n ails are advan ced in to
th e prox im al fragm en t ( Fig 5 .3 -6 ). In th is case, th e m edial n ail
sh ou ld be advan ced in to th e fem oral n eck an d th e lateral n ail
toward th e greater troch an ter. Th is is n ot as far as for su btro-
ch an teric fractu res (see Fig 5 .2-9 ). Ju st prior to advan cin g th e
n ails to th eir n al position , th ey are cu t leavin g en ou gh len gth
to m an ipu late an d advan ce th em fu rth er (see Fig 5 .3 -7 ).

Fig 5 .3 -5 Secon d n ail. Fig 5 .3 -6 Fractu re redu ction .

Th e rst n ail is advan ced prox im al to th e fractu re zon e. On ce both n ails h ave reach ed th e fractu re site, th e lateral on e
Likew ise, th e secon d precon tou red n ail is in serted in to th e (th e rst n ail in serted) is m an ipu lated to en ter th e m edu llar y
en tran ce site an d advan ced prox im al to th e fractu re site. can al of th e proxim al fragm en t so as to com plete th e redu c-
tion of th e fractu re. Th e secon d n ail is th en advan ced to th e
proxim al fragm en t.

121
 5 Fe m u r

3 Re d u ct io n a n d fixa t io n (co n t)

Fin a l p o s it io n in g In th e n al redu ction th e tips sh ou ld be align ed so th at th e

On ce th e n ail tips are in th eir n al position , th e en d of lateral n ail tip is d irected toward th e greater troch an ter an d
each n ail is cu t leavin g 1–2 cm protru d in g from th e cortex th e m ed ial n ail tip is d irected toward th e n eck of th e fem u r.
( Fig 5 .3 -8 ). Th e len gth depen ds on th e am ou n t of soft-tissu e Note th at th e n al location of th e n ail tips for stabilizin g sh aft
coverage arou n d th e tips. After cu ttin g to th e n al len gth , fractu res is n o fu rth er th an th e level of th e m ost proxim al
caps are placed over th e protru din g en ds of th e n ails to protect portion of th e lesser troch an ter.
th e soft tissu es.

a b

Fig 5 .3 -7 Prox im al advan cem en t. Nail protection .

Fig 5 .3 -8 a – b
Th e en ds of th e n ails are rst cu t leavin g su f cien t len gth to On ce th e n ails are in th eir n al position th ey are cu t again
con tin u e th eir easy passage proxim ally. En ou gh len gth is left leavin g on ly 1–2 cm protru d in g ou tside th e cortex. Plastic
so th at th e tips can be advan ced to ju st above th e level of th e caps or en d caps are placed over th e cu t en d. Th e wou n d is
lesser troch an ter (dotted n ail tips). For m ost sh aft fractu res closed.
advan cem en t of th e tips to th e level of th e lesser troch an ter is
u su ally su f cien t.

12 2
 5 .3 Fe m o ra l s h a ft fra ct u re , t ra n s ve rs e (3 2 -D/ 4 .1)

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Postoperative x-rays ( Fig 5 .3 -9 ) dem on strate satisfactory posi- By 3 m on th s postoperatively a proliferative callu s h as devel-
tion in g of th e n ails w ith th e tips ju st proxim al to th e lesser oped arou n d th e fractu re site ( Fig 5 .3 -10 ). X-rays taken at 8
troch an ter. Th ere is good separation of th e n ails in th e fractu re m on th s postoperatively follow in g n ail rem oval dem on strate
zon e. Protected weigh t bearin g can be allowed. com plete rem odelin g of th e in itial callu s ( Fig 5 .3 -11).

a b a b a b

Fig 5 .3 -9 a – b AP an d lateral x-rays Fig 5 .3 -10 a – b AP a n d latera l x-rays Fig 5 .3 -11a – bAP an d lateral x-rays
postoperatively dem on strate optim al t a ken at 3 m on t h s dem on st rate good taken 8 m on th s after n ail rem oval w ith
position in g of the n ails. Th e tips are ju st ca llu s su r rou n d in g t h e fract u re com plete rem odelin g of th e callu s.
proxim al to th e lesser troch an ter. Th ere site.
is good separation in th e fractu re zon e.

12 3
 5 Fe m u r

5 Alt e rn a t ive ca s e —u n s t a b le o b liq u e / s p ira l fe m o ra l s h a ft fra ct u re (32 -D/ 5 .1)

Even in lon g, u n stable spiral fractu res, ESIN can be Especially:

u sed. To preven t th e dan ger of sh orten in g correct respect of biom ech an ics
application of th e proper tech n iqu e is m an dator y. en tr y poin ts
n ail position in g an d placin g
preben d in g of n ails

A 10-year-old boy fell wh ile skatin g an d presen ted to th e em ergen cy

room w ith a swollen righ t th igh as h is on ly in ju r y. X-rays revealed a
spiral fractu re of th e m idsh aft of h is righ t femu r.

AP an d lateral in ju ry x-rays dem on stratin g a lon g spiral

Fig 5 .3 -12 a – b
a b
m idsh aft fractu re of h is righ t femu r w ith on ly m oderate sh orten in g.

Th e patien t was taken to su rgery an d th e fem u r was stabilized u sin g

th e ESIN tech n iqu e in exactly th e sam e m an n er as described in th e pre-
viou s case (see Figs 5 .3 -1 to 5 .3 -9 ). Postoperative x-rays dem on strate a
good an atom ical redu ction an d xation .

Fig 5 .3 -13 a – bAP an d lateral x-rays at 2 weeks postoperatively sh ow in g

th e fractu re redu ced an d excellen t separation of th e ten sion ben ds of th e
n ails at th e fractu re site.

Th e boy was perm itted fu ll postoperative m obilization . In th is case

m obilization was facilitated by th e u se of a con tinu ou s passive m otion
m ach in e (CPM) im m ed iately after su rger y. CPM is n ot u sed rou tin ely. It
is u sefu l in th ose patien ts wh o are slow in in itiatin g th eir postoperative
a b b
m otion .

Fig 5 .3 -14 Reestablish m en t of m otion can be facilitated w ith th e u se of

CPM.

12 4
 5 .3 Fe m o ra l s h a ft fra ct u re , t ra n s ve rs e (3 2 -D/ 4 .1)

5 Alt e rn a t ive ca s e —u n s t a b le o b liq u e / s p ira l fe m o ra l s h a ft fra ct u re (32 -D/ 5 .1) (co n t )

Proliferative callu s. Th e x-rays at 3 m on th s sh ow a stabi-

Fig 5 .3 -15 a – b
a b
lized fractu re w ith abu n dan t callu s. Th ere is also early rem odelin g.

Fig 5 .3 -16 a – b Com plete recover y. 8 m on th s after n ail rem oval, th e

patien t is fu lly active w ith n o leg len gth d iscrepan cy. X-rays dem on strate
a b
com plete rem odelin g of th e fractu re.

6 Pit fa lls – 7 Pe a rls +

Ap p ro a ch Ap p ro a ch

Fig 5 .3 -17 Th e in cision is

too proxim al an d too sm all.
If th e in cision is placed too Fig 5 .3 -18 Proper loca-
proxim al, th e obliqu e an gle 2–3 cm tion of th e in cision .
of in sertion m ay cau se th e Sym m etrical m ed ial an d
awl to in ju re th e distal en d lateral sk in in cision s start
of th e in cision . Th is cou ld at th e su perior poles of
resu lt in local n ecrosis w ith th e patella an d progress
a su bsequ en t in fection . proxim ally 2–3 cm .

12 5
 5 Fe m u r

6 Pit fa lls – (co n t) 7 Pe a rls + (co n t)

Fig 5 .3 -19 Th e en tran ce poin t is

directly adjacen t to th e physis. If th is
is th e case, th e per iph er y of th e
ph ysis can be in ju red du r in g drillin g
in an obliqu e d irection . Hen ce, th e
distal en tran ce sites sh ou ld be 1–2 cm
proxim al to th e edge of th e physis. Fig 5 .3 -2 2Th e en tran ce poin ts
are on th e sam e level.

Th e en tran ce
Fig 5 .3 -2 0 a – b
poin ts are n ot on th e sam e
level.
If th e en tran ce poin ts are
at differen t levels, th e n ails
m ay h ave u n equ al ten sion
forces. Th is can resu lt in
th e developm en t of an gu lar
a b
deform ities.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Perforation of th e opposite cortex.
If th e n ail is n ot advan ced in an obliqu e direction du rin g
in sertion , it can easily pen etrate th e th in cortex of th e
opposin g side of th e m etaph ysis. Fig 5 .3 -2 3 Obliqu e en tran ce can als.
Th e en tran ce can al n eeds to be
d irected obliqu ely. Th e tip can be
m ade to bou n ce off th e opposite
m etaph yseal cortex by effectin g a
secon d cu r ve ju st prox im al to th e
on e at th e tip.

Fig 5 .3 -21 Corkscrew ph en om en on . It is im portan t to always follow the path of th e n ail tip. If
Never tu rn th e n ail on its ow n axis by there is dif cu lty in advan cin g the n ail, rotate on e n ail
m ore th an 180°, as th is produ ces m ore u n der im age in ten si er con trol. Do n ot force th e n ail w ith
th an two n ail ju n ction s or th e “cork- th e h am m er if advan cin g it proxim ally is d if cu lt. It is
screw ph en om en on ”. Th is con gu ration always best to locate th e position of th e tip to see if it is
effectively elim in ates th e stabilizin g ef- wedged again st som e obstru ction .
fects of th e n ails.

126
 5 .3 Fe m o ra l s h a ft fra ct u re , t ra n s ve rs e (3 2 -D/ 4 .1)

6 Pit fa lls – (co n t) 7 Pe a rls + (co n t)

a b

Fig 5 .3 -2 7a – b Soft tissu es are best protected by u sin g en d

Fig 5 .3 -24 Crossin g th e n ails at th e caps.
fractu re site.
If th e n ails are n ot spread at th e frac-
tu re site, th ey do n ot exert ten sion
forces on th e fractu re fragm en ts an d,
th u s, m u ch of th e in tern al stability
is lost.

If th e en d is too prom in en t, pu ll th e n ail back an d recu t it,

reim plan t it, or replace it.

Fig 5 .3 -2 5 Leavin g th e en ds of th e
n ails too lon g ca n ir r itate th e sk in an d
block th e m ovem en t of th e k n ee.

a b

Fig 5 .3 -2 6 Th is sk in irr itation Fig 5 .3 -2 8 a – b Sh ape of d ifferen t cu tted n ails.

ca n progress to fu ll perforation an d a Nail en ds are cu tted w ith th e special n ail cu tter.
wou n d in fection . b Sh ar pe n ail en ds are cu tted w ith a n orm al n ail cu tter.

127
 5 Fe m u r

12 8
5.4 Fe m oral shaft re fracture , oblique (32-D/ 5.1)

1 Ca s e d e s crip t io n

A 7-year-old boy was in volved in a m otor veh icle acciden t in wh ich h e

su stain ed an obliqu e fractu re of th e m idsh aft of h is righ t fem u r. He was
treated im m ed iately follow in g th at prim ar y in ju r y w ith an extern al
xator. Th is in itial fractu re h ealed u n even tfu lly, an d th e xator was
rem oved at 10 weeks postfractu re. He appeared to be progressin g as
ex pected wh en at 4 weeks follow in g th e rem oval of th e xator h e ju m ped
from a ch air an d fell, su stain in g a n ew in ju ry to h is r igh t lower extrem -
ity. X-rays taken in th e em ergen cy room dem on strated a refractu re
th rou gh th e old fractu re site ( Fig 5 .4 -1 ). Com m on ly, fem oral fractu res
treated w ith an extern al xator sh ow poor callu s at th e old fractu re site.
Th is is felt to be du e to th e stress sh ield in g from th e xator.

Fig 5 .4 -1a – b In ju r y x-rays, taken im m ed iately post-refractu re. In

ad d ition to varu s an gu lation , th e d istal fragm en t is also in tern ally rotated
an d th ere is poor callu s.

2 Su rgica l a p p ro a ch

Th e su rgical approach is very sim ilar to th e on e u sed for th e prim ary

fractu res of th e fem oral sh aft follow in g th e stan dard ESIN tech n iqu e for
fem oral sh aft fractu res.

After th e extrem ity h as been su rgically prepped an d draped, bilateral

sym m etr ical in cision s are m ade ( Fig 5 .4 -2 ). Th e d istal sk in lan d m ark is
th e u pper pole of th e patella. Th e sk in an d th e fascia are in cised togeth er.
Blu n t d issection is th en con tin u ed th rou gh th e m u scle to th e bon e.
Im portan t: en su re th at th e en tran ce poin ts are ou tside th e join t capsu le
an d away from th e edge of th e ph ysis.

2– 3 cm

Fig 5 .4 -2 Sk in in cision s.
Sym m etrical m ed ial an d lateral sk in in cision s start at th e su perior pole
of th e patella an d progress 2–3 cm proxim ally.

12 9
 5 Fe m u r

2 Su rgica l a p p ro a ch (co n t)

Co r t ica l p e n e t ra t io n Na il s e le ct io n
Th e cortex is rst perforated by an awl. It is in itially placed 90° Determ in e th e correct d iam eter of th e n ail by m easu r in g th e
to th e cortex to keep it from slippin g off. On ce th e aw l is rm ly isth m u s of th e m edu llary can al on th e x-ray im age. Th e d iam -
seated on th e su rface of th e cortex, it is an gled so th at th e eter of th e n ail sh ou ld be 1/ 3 of th e m edu llar y can al at its
en tran ce ch an n el is 45º to th e cortex ( Fig 5 .4 -3 ). If th e cortex n arrowest poin t. It is im portan t to select iden tical n ails. Usin g
is very h ard, a dr ill m ay be n ecessar y to carefu lly pen etrate n ails of d ifferen t diam eters creates u n equ al ten sion leadin g to
th e cortex. varu s or valgu s m alalign m en t. A sm all extra ben d is m ade at
th e tip to facilitate its bou n cin g off th e opposite cortex.

Na il in s e r t io n
Carefu lly in sert th e rst n ail in to th e m edu llary can al by
h an d or by u sin g th e in serter ( Fig 5 .4 -4 ). In itially, it is often
easiest to in sert th e n ail tip by h an d. After its in sertion , th e
position of th e n ail is con rm ed w ith th e im age in ten si er.

Fig 5 .4 -4 First n ail.

The tip of the precontou red n ail
Fig 5 .4 -3 Placem en t of th e aw l. is in serted rst into the medu l-
Th e aw l is rst placed per pen d icu lar to lary can al and advanced proxi-
th e cortex an d rotated u n til it is well m ally. To facilitate its m aking
seated in th e bon e. At th is poin t, it is the rst tu rn again st the oppo-
th en an gu lated 45° to th e sh aft ax is to site in ner cortex, a slight cu rve
produ ce an obliqu e ch an n el in th e cor- is in itially m ade in the n ail ju st
tex. proxim al to the tip.

13 0
 5 .4 Fe m o ra l s h a ft re fra ct u re , o b liq u e (32 -D/ 5 .1)

2 Su rgica l a p p ro a ch (co n t) 3 Re d u ct io n a n d fixa t io n

Carefu lly advan ce th e rst n ail toward th e fractu re zon e. Fol- Fra ct u re re d u ct io n
low in g th is, th e secon d n ail is in serted in to its en tran ce site At the fractu re site, on e of th e n ails is u su ally m an ipu lated in
an d advan ced to th e fractu re zon e ( Fig 5 .4 -5 ). Th e order su ch a m an n er th at its tip redu ces th e fragm en ts. On ce th e
in w h ich th e n ails are passed depen ds u pon wh ich on e passes redu ction h as been accom plish ed, both n ails are advan ced in to
m ore easily. th e proxim al fragm en t ( Fig 5 .4 -6 ). In th is case, th e m ed ial n ail
sh ou ld be advan ced in to th e fem oral n eck an d th e lateral n ail
toward th e greater troch an ter. Th is is n ot as far as w ith su btro-
ch an teric fractu res (see Fig 5 .2 -7 ). Ju st prior to advan cin g th e
n ails to th eir n al position , th ey are cu t ( Fig 5 .4 -7 ), leavin g
en ou gh len gth to m an ipu late an d advan ce th em fu rth er.

Fig 5 .4 -5 Secon d n ail. Fig 5 .4 -6 Fractu re redu ction .

Th e rst n ail is advan ced prox im ally to th e fractu re zon e. On ce both n ails h ave reach ed th e fractu re site, on e of th em is
Likew ise, th e secon d precon tou red n ail is in serted in to th e m an ipu lated to en ter th e m edu llary can al of th e proxim al
en tran ce site an d advan ced prox im ally to th e fractu re site. fragm en t an d to com plete th e redu ction of th e fractu re. Both
n ails are th en advan ced proxim ally in to th e prox im al frag-
m en t.

131
 5 Fe m u r

3 Re d u ct io n a n d fixa t io n (co n t)

Fin a l p o s it io n in g
On ce th e n ail tips are in th eir n al posi-
tion , th e en d of each n ail is cu t leavin g
1–2 cm protru d in g from th e cortex
( Fig 5 .4 -8 ). Th e am ou n t left protru d in g
is depen den t u pon th e am ou n t of soft-
tissu e coverage arou n d th e tips. After
cu ttin g to th e n al len gth , caps are
placed over th e protru d in g en ds of th e
n ails to protect th e soft tissu es.

Tip s d ive rge

In th e n al redu ction th e tips sh ou ld be
align ed so th at th e lateral n ail tip is
d irected toward th e greater troch an ter
an d th e m ed ial n ail tip is directed toward
th e n eck of th e fem u r ( Fig 5 .4 -8 ). Note
th at th e n al location of th e tips of th e
n ails for stabilizin g sh aft fractu res is
advan ced on ly u p to th e level of th e
m ost proxim al portion of th e lesser tro-
ch an ter.

a b

Fig 5 .4 -7 Prim ar y n ail cu ttin g. Nail protection .

Fig 5 .4 -8 a – b
Th e en ds of th e n ails are rst cu t, leav- On ce th e n ails h ave been advan ced to
in g su f cien t len gth to con tin u e th eir th eir n al position , th ey are cu t again
easy passage proxim ally. En ou gh len gth leavin g on ly 1–2 cm protru d in g ou tside
is left so th at th e tips can be advan ced th e cortex. Plastic caps or en d caps are
to ju st above th e level of th e lesser placed over th e cu t en d. Th e wou n d is
troch an ter. For m ost sh aft fractu res closed.
advan cem en t of th e tips to th is level is
u su ally su f cien t.

132
 5 .4 Fe m o ra l s h a ft re fra ct u re , o b liq u e (32 -D/ 5 .1)

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Becau se of th e stability of th e fractu re follow in g ESIN, th e patien t can

begin im m ed iate m obilization progressin g rapidly to weigh t bear in g as
tolerated u sin g cru tch es.

Th e rst follow-u p x-rays are u su ally taken at abou t 2 –4 weeks post-

operatively.

Th e position of th e fractu res an d n ails sh ou ld be u n ch an ged. Depen din g

u pon th e origin al severity of th e fractu re an d rate of retu rn of m otion
an d m u scle stren gth , th e ch ild is seen at th e appropriate in ter vals. On ce
th e fractu re h as h ealed an d th e callu s h as rem odeled ( Fig 5 .4 -9 ), th e ch ild
is sch edu led for n ail rem oval.

AP an d lateral x-rays taken at 8 m on th s postoperatively

Fig 5 .4 -9 a – b
dem on strate obliteration of th e fractu re lin e an d th e defects from th e
a b
xator pin s.

133
 5 Fe m u r

13 4
5.5 Se gm e ntal fe m oral shaft fracture (32-D/ 5.2) and
ipsilate ral tibial shaft fracture (42-D/ 5.1)
1 Ca s e d e s crip t io n

A 7-year-old boy in ju red in a car-pedestrian acciden t

presen ted w ith m u ltiple system in ju ries. His life-th reaten -
in g con d ition s in clu ded a closed h ead in ju ry an d blu n t
trau m a to th e ch est.

Th e patien t’s m ajor orth oped ic con cern s in clu ded a seg-
m en tal fractu re of th e righ t fem oral sh aft w ith sh orten in g
( Fig 5 .5 -1). Add ition ally, h e su ffered from an obliqu e frac-
tu re of th e m idsh aft of th e ipsilateral tibia w h ich was on ly
m in im ally displaced an d sh orten ed ( Fig 5 .5 -2 ).

In th is case of polytrau m a an d u n der th e aspect of prim ary

care an d reh abilitation th e isolated tibial sh aft fractu re h as
to be operated too.
Fig 5.5 -1 Fem oral fractu re. Fig 5 .5 -2 Tibial fractu re.
Th e fractu res are obliqu e Th e ipsilateral factu re of th e
an d tran sverse an d are tibia is an isolated obliqu e
located at th e ju n ction s of fractu re pattern located in
th e prox im al-m idd le an d th e m id-sh aft.
m idd le-d istal segm en ts of
th e sh aft.

In it ia l s t a b iliza t io n Co n ve r t t o t w o s e gm e n t s
Th e patien t’s poten tially life-th reaten in g con d ition s were Th e basic prin ciple in treatin g a segm en tal fractu re is to rst
evalu ated w ith CT scan s of th e h ead an d th orax. In add ition , con vert it to two workable segm en ts. An evalu ation of th e
a tu be was in serted in to on e of th e ven tricles to m on itor pattern an d location of th e fractu res w ill determ in e wh ich
for in creases in th e in traven tricu lar pressu re. Fortu n ately, segm en ts sh ou ld be con n ected rst. Th is sam e evalu ation w ill
th ese in itial evalu ation s dem on strated th at h e h ad n o life- also determ in e wh eth er th e n ailin g procedu re sh ou ld be
th reaten in g con d ition s an d was n eu rologically an d h em ody- perform ed an te- or retrograde.
n am ically stable.
Re t ro gra d e n a ilin g
Fe m u r s t a b ilize d in it ia lly In th is patien t, becau se th ere was on ly a relatively sh ort
On ce it was determ in ed th at th e boy was stable en ou gh to be am ou n t of cortex prox im ally, it was felt th at th e stabilization
an esth etized, h e was tran sferred to th e operatin g room an d cou ld be best perform ed in retrograde tech n iqu e.
was position ed su pin e on a rad iolu cen t operatin g table. It was
elected to stabilize th e fem u r rst.

135
 5 Fe m u r

2 Su rgica l a p p ro a ch

Sk in in cis io n s Co r t ica l p e n e t ra t io n
After th e extrem ity h as been su rgically prepped an d draped, Th e cortex is rst perforated by an aw l. It is in itially placed 90°
bilateral sym m etrical in cision s are m ade ( Fig 5 .5 -3 ). Th e d istal to th e cortex to keep it from slippin g off. On ce th e awl is rm ly
sk in lan dm ark is th e u pper pole of th e patella. Th e sk in an d seated on th e su rface of th e cortex, it is an gled so th at th e
th e fascia are in cised togeth er. Blu n t d issection is th en con tin - en tran ce ch an n el is 45° to th e cortex ( Fig 5 .5 -4 ). If th e cortex
u ed th rou gh th e m u scle to th e bon e. Im portan t: En su re th at is very h ard, a d rill m ay be n ecessary to carefu lly pen etrate
th e en tran ce poin ts are ou tside th e join t capsu le an d away th e cortex.
from th e edge of th e physis.

2–3 cm

Fig 5 .5 -3 Sk in in cision s. Fig 5 .5 -4 Placem en t of th e aw l.

Sym m etr ical m edial an d lateral sk in in cision s start at th e Th e awl is rst placed per pen d icu lar to th e cortex an d rotated
su per ior pole of th e patella an d progress 2–3 cm prox im ally. u n til it is well seated in th e bon e. At th is poin t, it is th en an gu -
lated 45° to th e sh aft axis to produ ce an obliqu e ch an n el in th e
cortex.

13 6
 5 .5 Se gm e n t a l fe m o ra l s h a ft fra ct u re (32 -D/ 5 .2) a n d ip s ila t e ra l t ib ia l s h a ft fra ct u re (4 2 -D/ 5 .1)

2 Su rgica l a p p ro a ch (co n t) 3 Re d u ct io n a n d fixa t io n

Na il s e le ct io n Dis t a l fra ct u re re d u ct io n
Determ in e th e correct diam eter of th e n ail by m easu rin g th e At th e fractu re site, on e of th e n ails is m an ipu lated in su ch a
isth m u s of th e m edu llary can al on th e x-ray im age. Th e d iam - m an n er th at its tip redu ces th e d istal fragm en t to th e m iddle
eter of th e n ail sh ou ld be 1/ 3 of th e m edu llary can al at its fragm en t. On ce both n ails h ave reach ed th e d istal fractu re
n arrowest poin t. It is im portan t to select iden tical n ails. Usin g site, th e rst n ail is th en advan ced u p to th e prox im al fractu re
n ails of d ifferen t d iam eters creates u n equ al ten sion s lead in g site ( Fig 5 .5 -6 ).
to varu s or valgu s m alalign m en t. A sm all extra ben d is m ade
at th e tip to facilitate its bou n cin g off th e opposite cortex .

Na il in s e r t io n
Carefu lly in sert th e n ail in to th e m edu llar y can al by h an d or
by u sin g th e T-h an dle in serter ( Fig 5 .5 -5 ). In itially it is often
easiest to in sert th e n ail tip by h an d. After its in sertion , th e
position of th e n ail is con rm ed w ith th e im age in ten si er.

Carefu lly advance the rst n ail toward the distal fractu re zone.
Follow in g th is, the second n ail is in serted into its entrance site
and advanced to the same fractu re zone. The order in wh ich the
n ails are passed depends upon wh ich one passes more easily.

Fig 5 .5 -5 First n ail in sertion . Fig 5 .5 -6 Distal fractu re redu ction .

Th e tip of th e precon tou red Th is rst n ail is advan ced proxim ally to th e distal fractu re
n ail is in serted rst in to th e zon e. Likew ise, th e secon d precon tou red n ail is in serted in to
m edu llar y can al an d advan ced its en tran ce site an d advan ced prox im ally to th e sam e fractu re
proxim ally. To facilitate its zon e. Next, th e rst n ail is advan ced to th e prox im al fractu re
m akin g th e rst tu rn again st zon e. On ce both n ails h ave reach ed th e fractu re site, on e of
th e opposite in n er cortex, a th em is m an ipu lated to en ter th e m edu llar y can al of th e prox i-
sligh t cu r ve is placed in th e m al fragm en t an d m an ipu lated so as to com plete th e redu c-
n ail ju st proxim al to th e tip. tion of th e fractu re.

137
 5 Fe m u r

3 Re d u ct io n a n d fixa t io n (co n t)

On ce th is rst redu ction h as been ach ieved, th e secon d n ail is Firs t n a il cu t s

advan ced fu lly in to th e m idd le fragm en t ( Fig 5 .5 -7 ). Once th is secondary reduction h as been ach ieved, the second
n ail is then advanced into the proxim al fragment. The excess
Pro xim a l fra ct u re re d u ct io n part of the n ail is rst trim med leaving on ly an amou nt protrud-
Th e th ree-segm en t fractu re h as n ow been con verted to two ing equ al to the distance needed to advance to the n al position
segm en ts. A secon d in d irect fractu re redu ction is again accom - plu s the 1–1.5 cm th at w ill be left protruding from the cortex
plish ed by m an ipu lation of on e of th e n ail tips an d by advan c- ( Fig 5.5 -9 ).
in g it in to th e m ost prox im al fragm en t ( Fig 5 .5 -8 ).

Fig 5 .5 -7 M id d le se gm e n t st a biliza- Fig 5 .5 -8Prox im al fractu re re du ction . Fig 5 .5 -9 Nail cu ttin g.

t ion . By m an ipu latin g on e of th e n ail tips, th e The ends of the n ails are rst cut, leavin g
Th e m iddle segm en t is stabilized to th e proxim al fractu re is also redu ced. su f cient len gth to con tinu e th eir easy
d istal segm en t as both n ails are th en passage proxim ally. En ou gh len gth is left
advan ced proxim ally in to th e cen tral so th at th e tips can be advan ced in to th e
fragm en t to th e prox im al fractu re zon e. proxim al fragm ent to ju st above th e level
of th e lesser troch an ter. For m ost sh aft
fractu res, advan cem en t of th e tips to th is
level is u su ally su f cien t.

13 8
 5 .5 Se gm e n t a l fe m o ra l s h a ft fra ct u re (32 -D/ 5 .2) a n d ip s ila t e ra l t ib ia l s h a ft fra ct u re (4 2 -D/ 5 .1)

3 Re d u ct io n a n d fixa t io n (co n t)

Fin a l a d va n ce m e n t to th e n al len gth , caps are placed over th e protru d in g en ds of

Both n ails are n ow ready to be advan ced in to th e proxim al th e n ails to protect th e soft tissu es.
fragm en t. In th is case, th e m ed ial n ail sh ou ld be advan ced
in to th e fem oral n eck an d th e lateral n ail towards th e greater Tip s d ive rge
troch an ter. In th e n al redu ction th e tips sh ou ld be align ed so th at th e
lateral n ail tip is d irected towards th e greater troch an ter an d
Fin a l p o s it io n in g th e m ed ial n ail tip is d irected toward th e fem oral n eck. Note
Nail cu ttin g. th at th e n al location of th e tips of th e n ails for stabilizin g
On ce th e n ail tips are in th eir n al position , th e en d of each sh aft fractu res is n o fu rth er th an th e level of th e m ost prox i-
n ail is th en cu t, leavin g 1–2 cm . protru din g from th e cortex m al portion of th e lesser troch an ter. Th is is n ot as far as w ith
( Fig 5 .5 -10 ). Th e am ou n t left protru d in g is depen den t u pon th e su btroch an teric fractu res (see Fig 5 .2 -10 ).
am ou n t of soft-tissu e coverage arou n d th e tips. After cu ttin g

a b

Nail protection .
Fig 5 .5 -10 a – b
On ce th e n ails h ave been advan ced to th eir n al position ,
th ey are cu t on e last tim e, leavin g on ly 1–2 cm protru d in g
ou tside th e cortex. Plastic caps or en d caps are placed over th e
cu t en d. Th e wou n d is closed.

139
 5 Fe m u r

4 St a b iliza t io n o f t h e ip s ila t e ra l t ib ia l s h a ft fra ct u re

Follow in g th e su ccessfu l stabilization of th e segm en tal fem oral fractu re,

th e tibia is stabilized u sin g th e ESIN tech n iqu e described in ch apter 6.
Th e n ails are in serted an d advan ced an tegrade via separate m ed ial an d
lateral en tran ce sites ( Fig 5 .5 -11 ).

Fig 5 .5 -11a – b AP an d lateral follow-u p x-rays of th e tibia dem on stratin g

fu ll h ealin g of th e tibial sh aft fractu re follow in g ESIN m an agem en t. In
th is case th e lateral n ail h as n ot been cu t sh ort en ou gh .

5 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Becau se of h is polytrau m a, th is you n g patien t rem ain ed

in th e ICU for a total of 3 weeks. Th e postoperative
x-rays dem on strated th at th e an atom ical redu ction was
m ain tain ed even th ou gh th ere was extern al im m obili-
zation . Th e patien t u n der wen t passive m otion by th e
th erapists du rin g th at tim e.

By week 4 th ere was su f cien t callu s visible on th e

x-rays of both fractu res to perm it fu ll weigh t bearin g
( Fig 5 .5 -12 ).

At 8 m on th s post-in ju ry, th e patien t h ad regain ed fu ll

recovery of h is mu scle stren gth an d rem odelin g of th e
fractu re callu s ( Fig 5 .5 -13 ) to sch edu le n ail rem oval.

AP an d lateral
Fig 5 .5 -12 a – b Fig 5 .5 -13 a – bAP an d lateral
x-rays 4 weeks postoperatively. x-rays at 8 m on th s dem on strate
su f cien t rem odelin g to perm it
n ail rem oval.

14 0
5.6 Distal fe m oral fracture (33 -M/ 3.1)

1 Ca s e d e s crip t io n

13-year-old m ale fell wh ile sk iin g.

He presen ted at th e h ospital w ith
a tem porar y spica cast. X-rays taken
in th e em ergen cy room sh owed a
tran sverse d istal fem oral fractu re
( Fig 5 .6 -1).

Fig 5 .6 -1a – dTran sverse fractu re of

a b c d
th e d istal femu r.

2 Su rgica l a p p ro a ch

An t e gra d e a p p ro a ch
Th is fractu re pattern is best stabilized w ith th e ESIN tech n iqu e u sin g an an tegrade
approach . Th u s th e en tran ce poin ts n eed to be in th e prox im al fem u r.
3 – 5 cm
Sk in in cis io n
Make a 3 –5 cm sk in in cision in th e lateral aspect of th e su btroch an teric region ( Fig 5 .6 -2 ).
Th e in cision n eeds to exten d proxim ally from th e en tran ce sites to allow su f cien t
space to be able to advan ce th e n ails an tegrade at an an gle to th e cortex. Next, spread
th e fascia an d m u scle to ex pose th e an terolateral cortex of th e fem u r d istal to th e
greater troch an ter.

Fig 5 .6 -2Sk in in cision .

Th e proxim al skin in cision starts ju st below th e greater troch an ter an d exten ds distally
3 –4 cm to ju st below th e lesser troch an ter. It n eeds to be su f cien t to allow en ou gh
ex posu re of th e prox im al sh aft to accom odate th e two separate en tran ce sites (sm all
circles).

141
 5 Fe m u r

2 Su rgica l a p p ro a ch (co n t)

En tra n ce s ite s Na il in s e rtio n

Two separate en tran ce sites 2 –3 cm apart are m ade in th e Th e rst n ail, wh ich h as been precon tou red in its d istal 1/ 3rd,
lateral cortex. Be carefu l, if th e en tran ce sites are too close, is in serted in to th e in tram edu llary can al an d advan ced an te-
th e cortex m ay split du r in g in sertion of th e n ails. Th e en tran ce grade towards th e fractu re site ( Fig 5 .6 -4 ).
site is m ade w ith th e awl. It is rst started per pen d icu lar to
th e cortex. On ce it h as en gaged, th e aw l is directed at a 45°
an gle an d d rillin g is con tin u ed in th is direction to com plete
th e can al in th e cortex ( Fig 5 .6 -3 ). Th ese en tran ce can als n eed
to be d irected abou t 45° distally to facilitate an tegrade
advan cem en t of th e n ails.

Fig 5 .6 -3En tran ce sites. Fig 5 .6 -4 First n ail in sertion .

On ce en gaged, th e awl is directed 45° to th e sh aft Th e rst n ail is in serted an d advan ced an tegrade.
axis to facilitate an tegrade advan cem en t of th e
n ails.

14 2
 5 .6 Dis t a l fe m o ra l fra ct u re (33 -M/ 3 .1)

3 Re d u ct io n a n d fixa t io n

Th e secon d n ail wh ich is in itially con tou red th e sam e as th e rotatin g th e n ail 180°. To com plete th e S con tou rin g, th e prox-
rst is th en in serted in to th e secon d en tran ce site an tegrade im al portion of th e n ail still ou tside th e en tran ce site is ben t
as well. On ce it h as good con tact w ith th e opposite cortex, in a d istal d irection by alm ost 90° ( Fig 5 .6 -6 ). Th is w ill con vert
w ith th e tip h avin g advan ced abou t 2/ 3rds d istally in th e th e n ail to a S-sh ape w h ich w ill provide perfect in n er con tact
m edu llar y can al, th e con tou rin g of th e n ail is ready to be w ith th e lateral cortex at th e fractu re site an d th e m ed ial
ch an ged to an S-sh ape ( Fig 5 .6 -5 ). Th is is accom plish ed by rst cortex of th e prox im al fem u r.

18 0 °

Fig 5 .6 -5 Secon d n ail in sertion . Fig 5 .6 -6 S-sh ape con tou r in g.

Th e secon d n ail is advan ced u n til th ere is good con tact between Th e n ail is rst rotated 180° placin g th e origin al con tou r cu r ve
it an d th e m ed ial cortex alon g th e len gth of its cu rvatu re. in con tact w ith th e lateral cortex. Th e portion of th e n ail still
ou tside th e en tran ce site is th en ben t d istally by abou t 90°.

14 3
 5 Fe m u r

3 Re d u ct io n a n d fixa t io n (co n t)

Dis t a l fra gm e n t a d va n ce m e n t Fin a l s e a tin g

If th e fractu re is redu ced both n ail tips are th en advan ced past Advan ce th e n ails to th e epiphyseal plate w h ere th ey are
th e fractu re site in to th e d istal fragm en t ( Fig 5 .6 -7 ). im pacted m ed ially an d laterally in to th eir respective con dylar
region s ( Fig 5 .6 -8 a ). At th is tim e it is im portan t to align th e
n ail tips so th at th ey d iverge from on e an oth er. If th e fractu re
is very d istal, th e ph ysis can be perforated w ith th e n ails. It
h as been ou r experien ce th at th is does n ot produ ce any grow th
arrest ( Fig 5 .6 -8 b ). Cu t th e en ds an d protect th e soft tissu e
w ith caps ( Fig 5 .6 -8 c).

a c

Fin al seatin g.
Fig 5 .6 -8 a – c
Fig 5 .6 -7 Distal advan cem en t. After th e tips h ave reach ed th eir n al position , th ey are
On ce th e fractu re is redu ced, both n ails are advan ced im pacted in to th e d istal fragm en t an d cu t off prox im ally.
in to th e d istal fragm en t. Plastic caps or en d caps are placed over th e cu t en d. Th e wou n d
is closed.

14 4
 5 .6 Dis t a l fe m o ra l fra ct u re (33 -M/ 3 .1)

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

The postoperative cou rse was u ncom plicated. Becau se of the h asten h is overall recovery. At 6 weeks good bon e h ealin g was
stability afforded by ESIN, the patient was able to in itiate early visible ( Fig. 5 .6 -12 ). Th e n ails were rem oved at 1 year, by 2
motion almost im mediately postoperatively. years on ly 4 m m of len gth d iscrepan cy an d fu ll k n ee m otion
was fou n d.
Th e postoperative x-rays sh ow an atom ically redu ction
( Fig 5 .6 -9 ). Weigh t bearin g w ith cru tch es was in itiated as soon Th is ability to resu m e early m otion en abled h im to h asten h is
as th e im m ed iate postoperative pain h ad su bsided. X-rays at 2 overall recovery. Th e n ails were rem oved at on e year. By 2
days an d 2 weeks sh owed u n ch an ged align m en t ( Figs 5 .6 -10 years th e x-rays dem on strated fu ll rem odelin g w ith on ly 4 m m
an d 5 .6 -11). Th e ability to resu m e early m otion en abled h im to of len gth discrepancy an d fu ll kn ee m otion ( Fig 5 .6 -10 ).

Fig 5 .6 -9 a – b AP an d lateral x-rays

taken im m ediately after su rgery. Th e
redu ction h as alm ost obliterated th e
origin a l fractu re lin e. Th e n ail tips lie
a b
d ivergen tly.

a b a b a b

Fig 5 .6 -10 a – b Postoperative x-rays after 2 Fig 5 .6 -11a – b Follow-u p x-rays after 2 Fig 5 .6 -12 a – b Follow-u p x-rays after 6
days sh ow correct axial align m en t of th e weeks sh ow good rem odelin g of th e weeks sh ow good bon e h ealin g.
fractu re. bon e.

14 5
 5 Fe m u r

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Retrograde n ail m ay produ ce an u n stable con stru ct. Th e prox im al approach produ ces on ly m in im al scarin g.

Re d u ct io n a n d xa t io n Re d u ctio n a n d xa t io n
Becau se of th e n eed for separation of th e en tran ce sites If th e fractu re is u n stable du e to com m inu tion ,
proxim ally, th e n ail len gth s are u n equ al. Th erefore, th ere a sm all extern al xator can be applied to m ain tain
n eeds to be an an atom ical redu ction . len gth tem porarily.

b c d

e f g h

Fig 5 .6 -13 a – h
a Mu ltifragm en tary fractu re in osteoporotic bon e.
b ESIN w ith add ition al sm all extern al xator, AP view.
c ESIN w ith addition al sm all extern al xator, lateral view.
d Th e extern al xator can be rem oved if callu s is visible.
e Healin g after 3 m on th s, AP view.
f Healin g after 3 m on th s, lateral view.
g Follow-u p after 1 year, AP view.
h Follow-u p after 1 year, lateral view.

14 6
 5 .6 Dis t a l fe m o ra l fra ct u re (33 -M/ 3 .1)

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Re d u ct io n a n d xa t io n (co n t) Re d u ctio n a n d xa t io n (co n t)

a b c d

a b c d e

Fig 5 .6 -15 a – eAn 8-year-old boy fell wh ile skiin g an d

presen ted w ith a pain fu l an d swollen left th igh .
Th is was an isolated in ju ry. X-rays revealed an obliqu e
fractu re of th e distal left femu r.
a Obliqu e fractu re of th e d istal femu r.
e f g h b – c AP an d lateral x-rays taken im m ed iately follow in g
th e su rgery. Th e redu ction h as alm ost obliterated th e
5 .6 -14 a – h Un stable con stru ct. origin al fractu re lin e. Th e n ail tips lie divergen tly.
a – b A 14 year-old-m ale was in volved in an car-pedestrian d – e Com plete rem odelin g. AP an d lateral x-rays taken 2
acciden t. On presen tation to th e em ergen cy room , years post-fractu re dem on strate com plete rem odelin g
h is on ly physical n d in g was a swollen righ t th igh . X- of th e fractu re site.
rays dem on strated a com pletely d isplaced tran sverse
fractu re th rou gh th e distal femu r at th e diaphyseal-
m etaph yseal ju n ction .
c– d He was treated w ith ESIN u sin g a retrograde
approach .
e – f Th is, h owever, was n ot a stable con stru ct. Becau se
th e en tran ce sites were close to th e fractu re site
th e n ails crossed at th e fractu re site providin g very
little in trin sic stability. As a resu lt h e requ ired
extern al im m obilization wh ich delayed th e on set of
early m otion resu ltin g in a prolon ged postoperative
reh abilitation period.
g– h Fortu n ately, h is fractu re progressed to fu ll h ealin g.

147
 6 Tib ia

6 Tibia

6 .1 In t ro d u ct io n —t ib ia l fra ct u re s 14 9
1 In d ica tio n s 14 9
2 Pa tie n t p re p a ra tio n a n d p o sitio n in g 14 9
3 Su rgica l p rin cip le 15 0
4 Im p la n t re m o va l 15 0
5 Su gge ste d re a d in g 15 0

6 .2 Tib ia l a n d fib u la r m id s h a ft fra ct u re , o b liq u e (42 -D/ 5 .1) 151

6 .3 Is o la t e d t ib ia l s h a ft fra ct u re , o b liq u e (42 t-D/ 5 .1) 157

6 .4 Tib ia l m id s h a ft fra ct u re , w e d ge (42 t-D/ 5 .2) 16 3

14 8
6 .1 Introduction —tibial fracture s

1 In d ica t io n s

Som e fractu res of th e tibia h ave an acceptable align m en t an d Un stable fractu res in wh ich a satisfactor y align m en t can
can be im m obilized sim ply w ith a plaster cast. Th ose fractu res n ot be m ain tain ed by extern al im m obilization alon e.
wh ich m ay requ ire a m an ipu lation to ach ieve an acceptable Gu stilo type II an d III open fractu res.
align m en t prior to th eir bein g im m obilized can presen t w ith Fractu res associated w ith vessel an d/or n erve in ju ries.
on e of th e follow in g con d ition s:
An te- or recu rvatu re > 10°. Th e trian gu lar sh ape of th e tibial h ead, th e two lateral plan es
Lateral displacem en t exceed in g 1/ 2 th e diam eter of th e tilted for wards, an d th e rem ote m edu llary cavity m ean th at
sh aft. n ails can n ot be in serted laterally as in th e fem u r. To preven t
Varu s or valgu s an gu lation > 10°. recu r vation of th e tibial sh aft cau sed by th e dorsal m ovem en t
Sh orten in g. of th e n ail apexes, n ails m u st be in serted at a speci c poin t
Rotation al m alalign m en t. w ith th e apexes rotated dorsally.
Malalign m en t of u p to 10° can be im m obilized in itially Moreover, th e fact th at th e tibia is asym m etr ical in relation to
w ith a plaster cast followed by corrective wedgin g of th e th e associated m u scu latu re often leads to m alu n ion or n on -
cast after 1 week. u n ion .

Op e ra t ive in d ica t io n s Is o la t e d t ib ia l s h a ft fra ct u re s

Wh ile a large n u m ber of fractu res of th e tibia can be m an aged With som e fractu res of th e tibial sh aft, th e bu la m ay rem ain
qu ite adequ ately by n on operative m eth ods, th ere are certain in tact. If th is occu rs, th e force of th e gastrocn em iu s-soleu s
situ ation s in wh ich operative in ter ven tion m u st be em ployed com plex is con verted from on e of sim ple sh orten in g to on e
to ach ieve an acceptable resu lt. Th e in d ication s for su rgical of rotation . Th is ch an ge in d irection of th e m u scle force can
m an agem en t in clu de: resu lt in th e tibia developin g varu s an gu lation . If th is varu s
Un stable fractu res of th e distal sh aft in clu din g th e adja- m alalign m en t sh ifts in to m ore th an 10°, it can be m an aged
cen t d istal m etaph ysis. on ly by operative in ter ven tion . Persisten ce of th is m alalign -
Irredu cible fractu res. m en t can prolon g th e h ealin g tim e an d presen t an in creased
risk for th e developm en t of pseu darth rosis.

2 Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Me d ica t io n Eq u ip m e n t
An tibiotic proph ylaxis is adm in istered accord in g to th e In add ition to th e u su al su rgical in stru m en ts n eeded for m ost
stan dard of care in th e local com m u n ity. Th rom bosis orth opedic procedu res, som e special equ ipm en t is essen tial.
proph ylax is is u su ally in d icated for m en stru atin g girls, over- Th is in clu des:
weigh t patien ts an d patien ts w ith pelvic in ju ries. Stan dard ESIN set
Nails:
2.0 –4.0 m m stain less steel or titan iu m ; 33% (1/ 3) of th e
m edu llar y can al of th e tibial sh aft at its n arrowest poin t.
Im age in ten si er

14 9
 6 Tib ia

2 Pa t ie n t p re p a ra t io n a n d p o s it io n in g (co n t ) 3 Su rgica l p rin cip le

Pa t ie n t p o s it io n in g Dire ct io n o f n a ilin g
Th e ch ild is placed in th e su pin e position w ith a su pport Th ese fractu res are always stabilized u sin g an an tegrade bilat-
placed u n der th e k n ee ( Fig 6 .1-1). It is im portan t to en su re eral passage of th e n ails.
th at leg len gth s can be com pared w ith each oth er at th e en d
of th e operation .
4 Im p la n t re m o va l

Im plan t rem oval can be perform ed after 4 m on th s if con -

solidation h as been con rm ed rad iologically. Th e patien t can
bear weigh t im m ediately afterward. Th e axial align m en t an d
leg len gth sh ou ld be evalu ated for u p to 2 years follow in g th e
in ju r y.
a

5 Su gge s t e d re a d in g

Sch alam o n J, A in ö d h o fe r H , Jo e ris A , e t al (2005)

Elastic stable in tram edu llary n ailin g (ESIN) in lower leg
fractu res.
Eur J Trauma; 31:19 –23.
Sch m it t e n be ch e r PP (2000)
Treatm en t option s for fractu res of th e tibial sh aft an d an k le
in ch ild ren .
Techn Orthop; 15:38 –53.
Till H , D ie t z H- G (2002)
Modern tren ds in th e treatm en t of lim b fractu res
in ch ild h ood: sh aft fractu res of th e lower leg.
b Kinder- und Jugendmedizin; 2:236 –238.
Wiss DA , Se gal D , Gu m bs V L, e t al (1986)
Fig 6 .1-1a – b Position in g of th e lim b. Flex ible m edu llary n ailin g of tibial sh aft fractu res.
a Th e in ju red leg is su pported w ith a h old in g device so th at J Trauma; 26 (12):1106 –1112.
both th e AP an d lateral im ages can be easily obtain ed
w ith ou t m u ch m ovem en t of th e extrem ity.
b Th e im age in ten si er is placed w ith en ou gh space to allow
its rotation to obtain a tru e AP im age of th e tibia.

15 0
6 .2 Tibial and bular m idshaft fracture , oblique (42-D/ 5.1)

1 Ca s e d e s crip t io n

A 9-year-old boy su stain ed an in ju ry to righ t tibia an d bu la ( Fig 6 .2 -1). Th ere

h is righ t leg w h en h e fell off h is bicycle. was also sign i can t soft-tissu e in ju ry in
He presen ted to th e em ergen cy room . th e d istal th ird of th e leg wh ich wou ld
X-rays revealed th e presen ce of an h ave m ade im m obilizin g th e fractu re
obliqu e fractu re of th e m idsh aft of h is dif cu lt w ith a cast alon e.

AP an d lateral x-rays dem -

Fig 6 .2 -1a – b
on stratin g obliqu e fractu res of th e m id-
sh aft of both th e tibia an d th e bu la.
Wh ile th ere was on ly m in im al sh orten -
in g, th e recu r vatu re of both fractu res
a b
was felt to be u n acceptable.

2 Su rgica l a p p ro a ch

Skin in cis io n s
2 cm Sym m etrical skin in cision s of 2 cm in tan eou s tissu e is d issected u n til th e
len gth are m ade at th e sam e level on th e dissection in stru m en t is in con tact w ith
m edial an d lateral sides of th e tibial th e cortex of th e prox im al m etaph ysis.
tu berosity ( Fig 6 .2 -2 ). To provide su f - In perform in g th e d issection , th e sk in
cien t room to in sert and advan ce th e n ail sh ou ld be in cised su f cien tly to provide
an tegrade, the in cision s mu st extend adequ ate soft-tissu e coverage of th e cu t
from th e plan n ed en try site. Th e su bcu - n ail en ds.

Fig 6 .2 -2 Th e en tran ce sites are situ -

ated on th e proxim al m edial an d lateral
m etaph yseal cortices 2 cm d istal to th e
tibial tu bercle.

151
 6 Tib ia

2 Su rgica l a p p ro a ch (co n t)

En tra n ce s ite s An te gra d e in s e rt io n

Th e cortex is perforated w ith an awl or drill. Th e pen etratin g Wh en in sertin g th e n ails in to th e m edu llar y can al it is im por-
in stru m en t is rst directed at an an gle of 90°. After th e cortex tan t to en su re th at th e tips are poin tin g in to th e m edu llar y
h as been perforated, th e drillin g is th en con tinu ed at an an gle can al ( Fig 6 .2 -4 ). As already m en tion ed, th e in sertion an gle
of 60° ( Fig 6 .2 -3 ). It m u st be rem em bered th at th e m edu llary sh ou ld be less steep to en su re con tact w ith th e opposite cortex.
cavity of th e proxim al tibial m etaph ysis h as a w ide trapezoidal If n ecessar y, pre-con tou r th e n ails to a m ore extrem e position .
form . Th is requ ires th at th e in sertion an gle be less steep th an Both n ails are in itially advan ced as far as th e fractu re site by
w ith th e rou tin e m eth od in th e oth er bon es to assu re th at th e eith er back an d forth rotation s of th e h an d le or by applyin g
n ails com e in to con tact w ith th e opposite cortex. gen tle h am m er blow s ( Fig 6 .2 -5 ).

Fig 6 .2 -3Drillin g of th e en try sites. Fig 6 .2 -4 Nail en tr y. Fig 6 .2 -5 In sertion to th e frac-

An aw l is u sed to create th e en tran ce site. It is Th e rst n ail en ters th e proxim al tu re site.
placed rst at 90° an d th en an gled to 60° to th e m edu llary can al. Notice th e Th e secon d n ail is in serted an d
sh aft axis to produ ce an obliqu e ch an n el in th e en tran ce an gle is less steep to th e tips are advan ced to th e frac-
cortex. en su re con tact w ith th e opposite tu re site prior to fractu re redu c-
cortex. tion .

152
 6 .2 Tib ia l a n d fib u la r m id s h a ft fra ct u re , o b liq u e (4 2 -D/ 5 .1)

3 Re d u ct io n a n d fixa t io n

Fra ctu re re d u ct io n Dis t a l in s e rt io n

For th e prelim in ary redu ction an d xation , th e n ail th at After th is rst n ail is secu rely seated in th e distal fragm en t,
sh ou ld be advan ced rst, is th e on e th at w ill m ost easily th e secon d n ail is th en advan ced u n der im age in ten si cation
en gage th e d istal fragm en t at th e fractu re site. Usu ally th e in to th e d istal fragm en t 1–2 cm beyon d th e fractu re lin e. Prior
fractu re can be redu ced by advan cin g th e tip of th is rst n ail to n al im plan tation , th e n ails are prelim in arily sh orten ed,
sligh tly in to th e distal fragm en t. On ce in side th e m edu llar y takin g in to accou n t th e in sertion len gth still requ ired plu s th e
cavity, th e tip can be rotated to align an d redu ce th e fractu re. on e cen tim eter of th e n ail th at w ill be left protru d in g.
On ce satisfactory align m en t h as been ach ieved, th e rst n ail De n itive an ch orage of th e n ails in th e m etaph ysis is accom -
is advan ced 1–2 cm across th e fractu re site in to th e d istal part plish ed by h am m er blow s on th e in serter or im pactor
of th e m edu llary cavity ( Fig 6 .2 -6 ). Th e im age in ten si er is ( Fig 6 .2 -7 ).
u su ally n ecessary at th is stage. On ce in th e distal fragm en t,
th e tip of th e n ail mu st be d irected toward th e sam e cortex
th at con tain s th e en tran ce site.

Fig 6 .2 -6 Fractu re redu ction . Fig 6 .2 -7 Prelim in ary cu t.

Th e tip of th e rst n ail en ters th e m edu llary can al of th e d istal Prior to th e n al seatin g, th e n ail is rst cu t, leavin g th e
fragm en t. Th e n ail tip can be rotated to im prove th e align - len gth of n ail equ al to th e m easu red d istan ce to be advan ced
m en t. Note th at th e tip is d irected towards th e sam e cortex as plu s th e on e cen tim eter of th e n ail th at w ill be left protru d in g
th e en tran ce site. from th e en tran ce site. Th e n ail tip is th en advan ced w ith th e
h am m er to lie ju st proxim al to th e d istal ph ysis.

15 3
 6 Tib ia

3 Re d u ct io n a n d fixa t io n (co n t) 4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Fin a l s e a tin g Po s to p e ra tive tre a tm e n t

Axial com pression to fractu re fragm en ts is applied to preven t Im m ed iately postoperatively a rad iological ch eck is m ade
leavin g th e fragm en ts in d istraction . A lim ited degree of ax ial w h ich in clu des th e en tire lower leg to con r m th e adequ acy
correction m ay be possible at th is stage by rotatin g th e n ail of th e overall redu ction an d align m en t ( Fig 6 .2 -9 ). Follow in g
tips. Preferably, th e tips sh ou ld poin t in a dorsal (posterior) th e su rgical procedu re, th e lim b can be placed on a cu sh ion or
d irection to restore th e ph ysiological an tecu r vatu re. Th e bev- on a foam splin t ( Fig 6 .2 -10 ). Add ition al im m obilization is
eled im pactor is u sed to advan ce th e n ail th e n al cen tim eter u su ally n ot n ecessary. Mobility is reestablish ed w ith active
to position both n ail tips im m ediately proxim al to th e d istal an d passive gu ided m ovem en ts of th e h ip, k n ee, an d an k le
ph yseal cartilage. If n ecessary, n ail en d caps can be applied. join ts. Weigh t bearin g depen ds on in dividu al pain . In som e
Th e sk in is closed over th e protru d in g on e cen tim eter of th e cases, a con tinu ou s passive m otion splin t (CPM) m ay be
n ail ( Fig 6 .2 -8 ). u tilized.

a b

Fig 6 .2 -8 Fin al position of n ails. AP an d lateral x-rays taken im m ediately post-

Fig 6 .2 -9 a – b
Th e en ds h ave been cu t leavin g on e cen tim eter of th e n ail en d operatively. Notice th e tips of both n ails are d irected poster i-
ex posed. Th e sk in is su tu red to em bed th ese ex posed tips. orly to m ain tain th e n orm al an tecu r vatu re of th e tibia.

15 4
 6 .2 Tib ia l a n d fib u la r m id s h a ft fra ct u re , o b liq u e (4 2 -D/ 5 .1)

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n (co n t)

Postoper-
Fig 6 .2 -10 a – b
atively AP and lateral Fig 6 .2 -11a – bAP an d
x-rays taken at 6 weeks lateral x-rays taken after
dem on strate abu n dan t n ail rem oval (6 m on th s
a b a b
callu s. postoperatively).

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Th e en tran ce can al is too steep w h ich w ill preven t con tact Less steep in sertion of th e n ail an d/or m ore extrem e
between th e n ail an d th e opposite cortex. precon tou rin g of th e n ail w ill en su re adequ ate con tact of
th e n ail w ith th e opposite cortex.
If th e in cision is too cran ial, th ere is a risk of in ju r y to th e
ph yseal cartilage.

Placin g th e in cision too dorsal or lateral can produ ce an

in ju ry to th e peron eal n erve.

In th e rare cases wh ere th ere is severe swellin g, closed Open redu ction via sm all in cision s—u n less fasciotom y
n ailin g is n ot possible. h as already been perform ed to treat com partm en t
syn drom e.

15 5
 6 Tib ia

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Ap p ro a ch (co n t) Ap p ro a ch (co n t)
If th e n ail tips poin t an teriorly, a xed recu r vatu re of th e Th e n ail tips m u st be orien ted in a posterior d irection
tibia m ay be created. prior to th eir de n itive an ch orage in th e d istal fragm en t
to create n orm al sh ape of th e tibia.

Re h a b ilit a t io n Re h a b ilit a t io n
It is n ecessary to perform sh orten in g as a secon d stage.
It is u n w ise to leave th e n ails protru d in g u n til con -
solidation , as th is m ay lead to sk in erosion an d su bse -
qu en t in fection .

Excessive protru sion of th e n ail en ds from

Fig. 6 .2 -12 a – b
th e cortex of th e prox im al fragm en t can resu lt in irritati-
on of th e soft tissu e w ith th e risk of sk in perforation .
a b c d

Fig 6 .2 -13 a – d
a – b AP an d lateral view of an u n stable lower leg frac-
tu re of a 12-year-old boy. High risk of sh orten in g.
c– d Lon gitu din al stability can be ach ieved by th e u sin g
en d caps. Th e postoperative x-rays sh ow perfect
align m en t an d correct len gth .

15 6
6 .3 Isolate d tibial shaft fracture , oblique (42t-D/ 5.1)

1 Ca s e d e s crip t io n

A 12-year-old girl fell w h ile perform in g in a tu m blin g even t an d su s-

tain ed an in ju r y to h er left leg. Sh e was taken im m ed iately to th e local
ch ildren ’s h ospital wh ere x-rays sh owed an isolated obliqu e fractu re of
h er left tibial sh aft. With th e in tact bu la, th e fragm en ts of th e tibia
ten ded to dr ift in to varu s align m en t. Ex perien ce h as sh ow n th at th is
an gu lation can n ot be con trolled w ith n on operative m eth ods alon e. It
was felt by th e treatin g su rgeon th at th is h igh -perform an ce ath lete
requ ired as n ear an atom ic align m en t as cou ld be obtain ed. ESIN was
ch osen to ach ieve th is en d resu lt.

AP an d lateral im ages of th e in itial x-rays dem on stratin g

Fig 6 .3 -1a – b
a b
both varu s and recu rvatu m an gu lation of th e fragm en ts.

2 Su rgica l a p p ro a ch

Skin in cis io n s
Sym m etrical skin in cision s 2 cm in len gth are m ade at th e sam e level on
2 cm
th e m ed ial an d lateral sides of th e tibial tu berosity ( Fig 6 .3 -2 ). To provide
su f cien t room to in sert an d advan ce th e n ail an tegrade, th e in cision s
m u st exten d cran ially from th e plan n ed en try site. Th e su bcu tan eou s
tissu e is d issected u n til th e d issection in stru m en t is in con tact w ith th e
cortex of th e prox im al m etaph ysis. In perform in g th e d issection , th e sk in
sh ou ld be in cised su f cien tly to provide adequ ate soft tissu e coverage of
th e cu t n ail en ds.

Fig. 6 .3 -2 a – b Sk in in cision s.
a Th e en tran ce sites are placed on th e prox im al m ed ial an d lateral
m etaphyseal cortices 2 cm d istal to th e tibial tu bercle.
a b
b Clin ical pictu re of location of th e in cision s (arrow s).

157
 6 Tib ia

2 Su rgica l a p p ro a ch (co n t)

En tra n ce s ite s An te gra d e in s e rt io n

Th e cortex is perforated w ith an awl or drill bit. Th e pen etrat- Wh en in sertin g th e n ails in to th e m edu llar y can al it is im por-
in g in stru m en t is rst d irected at an an gle of 90°. After th e tan t to en su re th at th e tips are poin tin g in to th e m edu llar y
cortex h as been perforated, th e drillin g is th en con tinu ed at an cavity ( Fig 6 .3 -4 ). As already m en tion ed, th e in sertion an gle
an gle of 60° ( Fig 6 .3 -3 ). It mu st be rem em bered th at th e m edu l- sh ou ld be less steep to en su re con tact w ith th e opposite cor-
lary cavity of th e proxim al tibial m etaph ysis is a w ide, trape- tex. If n ecessar y, pre-con tou r th e n ails to a m ore extrem e
zoidal form . Th is requ ires th at th e in sertion an gle be less steep position . Both n ails are in itially advan ced as far as th e frac-
th an w ith th e rou tine m eth od in th e oth er bon es to en su re tu re site by eith er back an d forth rotation s of th e h an d le or by
th at th e n ails com e in to con tact w ith th e opposite cortex. applyin g gen tle h am m er blow s ( Fig 6 .3 -5 ).

a b

Fig 6 .3 -3 a – b Dr illin g of en try poin ts. Fig 6 .3 -4 Nail en try. Fig 6 .3 -5 Advan cem en t
a Th e aw l is u sed to d rill th e en tran ce site. It is placed rst Th e rst n ail en ters th e prox i- to th e fractu re site. Th e
at 90 º an d th en an gled to 60 º to th e sh aft axis to pro- m al m edu llary can al. Notice th e secon d n ail is in serted
du ce an obliqu e ch an n el in th e cortex. en tran ce an gle is less steep to an d th e tips are advan ced
b Clin ical ph oto dem on stratin g th e n al an gu lation of th e en su re con tact w ith th e opposite to th e fractu re site prior
aw l requ ired to create th e en tran ce site. cortex. to fractu re redu ction .

15 8
 6 .3 Is o la t e d t ib ia l s h a ft fra ct u re , o b liq u e (42 t-D/ 5 .1)

3 Re d u ct io n a n d fixa t io n

Fra ctu re re d u ct io n Dis t a l in s e rt io n

For prelim in ary redu ction an d xation th e n ail th at sh ou ld be After th is rst n ail h as been secu rely seated in th e distal frag-
advan ced rst is th e on e th at w ill m ost easily en gage th e d istal m en t, th e secon d n ail is th en advan ced u n der im age in ten si -
fragm en t at th e fractu re site. Usu ally th e fractu re can be cation in to th e distal fragm en t 1–2 cm beyon d th e fractu re
redu ced by sligh tly advan cin g th e tip of th is rst n ail in to th e lin e. Prior to n al im plan tation , th e n ails are prelim in arily
d istal fragm en t. On ce in side th e m edu llary cavity, th e tip can sh orten ed takin g in to accou n t th e in sertion len gth still requ ired
be rotated to align an d redu ce th e fractu re. On ce satisfactory plu s th e on e cen tim eter of th e n ail th at w ill be left protru din g.
align m en t h as been ach ieved, th e rst n ail is advan ced 1–2 cm De n itive an ch orage of th e n ails in th e m etaphysis is accom -
across th e fractu re site in to th e d istal part of th e m edu llary plish ed by u sin g an in serter or im pactor ( Fig 6 .3 -7 ).
cavity ( Fig 6 .3 -6 ). Th e im age in ten si er is u su ally n ecessar y at
th is stage. On ce placed in th e distal fragm en t, th e tip of th e
n ail m u st be directed towards th e sam e cortex th at con tain s
th e en tran ce site.

Fig 6 .3 -6 Fractu re redu ction . Fig 6 .3 -7 Prelim in ary cu t.

Th e tip of th e rst n ail en ters th e m edu llary can al of th e d istal Prior to n al seatin g, th e n ail is rst cu t leavin g a len gth of
fragm en t. Th is n ail tip can be rotated to im prove th e align - n ail equ al to th e m easu red d istan ce to be advan ced plu s th e
m en t. Note th at th e tip is directed toward th e sam e cortex as on e cen tim eter of th e n ail th at w ill be left protru d in g from th e
th e en tran ce site. en tran ce site. Th e n ail tip is th en advan ced w ith th e h am m er
to lie ju st prox im al to th e d istal ph ysis.

15 9
 6 Tib ia

3 Re d u ct io n a n d fixa t io n (co n t) 4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Im m ed iately postoperatively, a rad iological ch eck is m ade wh ich in clu des th e en tire
lower leg to con rm th e adequ acy of th e overall redu ction an d align m en t ( Fig 6 .3 -9 ).
Follow in g th e su rgical procedu re, th e lim b can be placed on a cu sh ion or on a foam
splin t. If th e fractu re fragm en ts h ave adequ ate bu ttressin g, n o addition al im m obili-
zation is u su ally n eeded. Mobility is re-establish ed w ith active an d passive gu ided
m ovem en ts of th e h ip, k n ee an d an k le join ts w ith ou t weigh t bearin g ( Fig 6 .3 -10 ). In
som e cases, a con tinu ou s passive m otion splin t (CPM) m ay be u tilized ( Fig 6 .3 -11).

Fig 6 .3 -8 Fin al position .

Th e en ds h ave been cu t leavin g on e cen -
tim eter of th e n ail en d ex posed. Th e AP an d lateral x-rays taken im m e-
Fig 6 .3 -9 a – b
sk in is su tu red to en gu lf th ese exposed diately postoperative. Notice th at varu s an d
a b
tips. recu rvatu re h ave been corrected.

16 0
 6 .3 Is o la t e d t ib ia l s h a ft fra ct u re , o b liq u e (42 t-D/ 5 .1)

4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n (co n t)

Partial weigh t bearin g is perm itted accord in g to th e patien t’s

m otivation a n d pain sen sation . Often , th e ch ild w ill begin
protected weigh t bearin g on day 2 or 3. Su bsequ en t weigh t-
bearin g progresses as th e ch ild decides.

Fu ll weigh t-bearin g is gen erally ach ieved after 3 –4 weeks.

X-rays taken at 4 weeks often sh ow adequ ate callu s. By 6
m on th s th e fractu re site h as been com pletely obliterated an d
rem odeled to perm it n ail rem oval ( Fig 6 .3 -12 ).

a b a b

Fig 6.3-10 Active an d passive Fig 6 .3 -11 Postoperative AP an d lateral

Fig 6 .3 -12 a – b AP an d
Fig 6 .3 -13 a – b
gu ided m ovem en ts of th e re covery m ay be en h an ced x-rays taken at 7 m on th s lateral x-rays taken after
h ip, k n ee, an d an k le join ts by u tilizin g con tinu ou s postoperative dem on strate fu ll n ail rem oval (9 m on th s
can begin as soon as th e passive m otion for a sh ort con solidation an d early postoperative) sh ow
patien t’s pain allow s. period of tim e. rem odelin g. essen tially com plete
rem odelin g of th e fractu re
site.

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Th e en tran ce can al is too steep w h ich w ill preven t con tact Less steep in sertion of th e n ail an d/or m ore extrem e
between th e n ail an d th e opposite cortex. precon tou rin g of th e n ail w ill en su re adequ ate con tact of
th e n ail w ith th e opposite cortex.
If th e in cision is too cran ial, th ere is a risk of in ju r y to th e
ph yseal cartilage.
Placin g th e in cision too posteriorly or laterally can
produ ce an in ju ry to th e peron eal n er ve.

161
 6 Tib ia

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
It is essen tial to avoid a residu al fractu re gap. Th is Apply ax ial com pression at th e tim e of n al seatin g of th e
in creases th e risk of delayed h ealin g w ith possible n ail.
pseu darth rosis form ation .
Add itive m in im al stabilization can be accom plish ed by
Th ere m ay be a problem in ach ievin g a satisfactor y, closed m ean s of applyin g a m in i extern al xator (on e pin per
redu ction . fragm en t) for a m ax im u m of 3 weeks.

In su f cien t ax ial correction ach ieved by th e im plan t.

Use of too th in n ails w ill resu lt in in su f cien t stability.

Th is in creases th e risk th at th e n ail w ill ben d u n der load.

If th e n ail is too th ick th ere m ay n ot be en ou gh elasticity

wh ich can in crease th e risk of delayed h ealin g.
a b c d e f
If th e n ails tw ist like a corkscrew, th e in tern al stability
w ill be lost. Th is m u st be avoided. Fig. 6 .3 -14 a – f
a – b In stable lower leg sh aft fractu re w ith ben d in g wedge.
c-d ESIN an d add ition al lim ited extern al xation w ith
on e pin per fragm en t for 3 weeks.
e -f De n itive h ealin g an d con solidation w ith ESIN alon e.

It is im portan t to avoid align m en t in an tecu rvatu re. Th e n ail tips in th e d istal fragm en t sh ou ld be orien ted in a
posterior direction .

Re h a b ilit a t io n Re h a b ilit a t io n
Excessive protru sion of th e n ail en ds from th e cortex of
th e prox im al fragm en t can resu lt in irritation of th e soft
tissu e w ith a risk of sk in perforation .

Fig 6 .3 -15 Th e n ails n eed to protru d in g by ju st 1 cm .

Protection of th e en ds w ith a n ail en d cap w ill often
preven t irritation .

16 2
6 .4 Tibial m idshaft fracture , we dge (42t-D/ 5.2)

1 Ca s e d e s crip t io n

A 10-year-old girl su stain ed a severe in ju r y to h er righ t leg

wh ile sk iin g. Sh e presen ted to th e em ergen cy room at th e
local ch ild ren ’s h ospital w ith a swollen an d pain fu l righ t leg.
Her n eu rovascu lar fu n ction in th e extrem ity was in tact an d
th is appeared to be h er on ly in ju ry. Th e in itial x-rays dem on -
strated a m id-sh aft fractu re of th e righ t tibia w ith a large
m edially based wedge or bu tter y fragm en t at th e fractu re site
( Fig 6 .4 -1).

Fig 6 .4 -1AP view of th e in itial x-rays obtain ed in th e em er-

gen cy room . Th ere is a large m edially based wedge fragm en t
(arrow s).

2 Su rgica l a p p ro a ch

Skin in cis io n s
Sym m etrical sk in in cision s 2 cm in len gth are m ade
2 cm at th e sam e level on th e m ed ial an d lateral sides of
th e tibial tu berosity ( Fig 6 .4 -2 ). To provide su f -
cien t room to in sert an d advan ce th e n ail an te-
grade, th e in cision s m u st exten d cran ially from th e
plan n ed en tr y site. Th e su bcu tan eou s tissu e is d is-
sected u n til th e d issection in stru m en t is in con tact
w ith th e cortex of th e prox im al m etaph ysis. In
perform in g th e dissection , th e skin sh ou ld be
in cised su f cien tly to provide adequ ate soft-tissu e
coverage of th e cu t n ail en ds.

Fig 6 .4 -2 Th e en tran ce sites are placed on th e

proxim al m edial an d lateral m etaph yseal cortices
2 cm d istal to th e tibial tu bercle.

16 3
 6 Tib ia

2 Su rgica l a p p ro a ch (co n t)

En tra n ce s ite s in su f cien t stability w ith th e resu ltan t risk th at th e n ail w ill
Th e cortex is perforated w ith an awl or drill bit. Th e pen etratin g ben d u n der load. If th e n ail is too th ick, th en th ere is in su f -
in stru m en t is rst directed at an an gle of 90°. After th e cortex cient elasticity wh ich can increase the risk of delayed h ealin g.
h as been perforated, the drillin g is th en continued at an an gle
of 60° ( Fig 6 .4 -3 ). It mu st be rem em bered th at th e m edu llary An te gra d e in s e rt io n
cavity of th e proxim al tibial m etaphysis is a w ide, trapezoidal Wh en in sertin g th e n ails in to th e m edu llary can al it is im por-
form . Th is requ ires th at the in sertion an gle be less steep th an tan t to en su re th at th e tips are poin tin g in to th e m edu llar y
w ith the routine m ethod in the other bones to en su re th at the cavity ( Fig 6 .4 -4 ). As already m en tion ed, th e in sertion an gle
n ails com e in to con tact w ith th e opposite cortex. sh ou ld be less steep to en su re con tact w ith th e opposite cor-
tex. If n ecessary, precon tou r th e n ails to a m ore extrem e posi-
Ch o ice o f n a ils tion . Both n ails are in itially advan ced as far as th e fractu re
The choice of the correct n ail th ickness is especially im portan t site by eith er back an d forth rotation s of th e h an d le or by
for th ese u n stable fractu res. If the n ail is too th in , th ere m ay be applyin g gen tle h am m er blow s ( Fig 6 .4 -5 ).

Fig 6 .4 -3 Drillin g of sites. Fig 6 .4 -4 Nail en try. Fig 6 .4 -5 In sertion to th e fractu re site.
Th e awl is u sed to d rill th e en tran ce site. Th e rst n ail en ters th e prox im al m ed- Th e tips are advan ced to th e fractu re site
It is placed rst at 90 º an d th en an gled u llar y can al. Notice th e en tran ce an gle pr ior to fractu re redu ction .
to 60 º to th e sh aft ax is to produ ce an is less steep to en su re con tact w ith th e
obliqu e ch an n el in th e cortex. opposite cortex.

16 4
 6 .4 Tib ia l m id s h a ft fra ct u re , w e d ge (42 t -D/ 5 .2)

3 Re d u ct io n a n d fixa t io n

Effe ct o f w e d ge cavity ( Fig 6 .4 -6 ). Th e im age in ten si er is u su ally n ecessar y at

If th e wedge fragm en t is large, th en th ere is a lack of cortical th is stage. On ce in th e d istal fragm en t, th e tip of th e n ail m u st
bu ttressin g on th e side of th e wedge base. It m ay be best to be directed toward th e sam e cortex th at con tain s th e en tran ce
in itially in sert as th e rst n ail th e on e wh ich w ill h ave th e site.
m ax im u m ben d in g con tou r at th e apex of th e wedge. As a
resu lt, an exact redu ction m ay be m ore d if cu lt du e to th is Dis t a l in s e rt io n
in stability at th e fractu re site. Directin g th e n ail can be prob- After th is rst n ail is secu rely in th e distal fragm en t, th e sec-
lem atic w ith th is fractu re pattern . on d n ail is th en advan ced u n der im age in ten si cation in to th e
d istal fragm en t 1–2 cm beyon d th e fractu re lin e. However, its
Fra ctu re re d u ct io n tip m ay h ave to be rotated by a m ax im u m of 90 º in a an terior
For prelim in ar y redu ction an d xation th e n ail th at sh ou ld be or posterior direction . After crossin g th e distal fractu re lin e,
advan ced rst is th e on e th at w ill m ost easily en gage th e d istal th e tip m u st be brou gh t back to its or igin al position by rota-
fragm en t at th e fractu re site. Usu ally th e fractu re can be tion in th e opposite d irection . Prior to n al im plantation , the
redu ced by advan cin g th e tip of th is rst n ail sligh tly in to th e n ails are prelim in arily sh ortened, takin g into accou nt the in ser-
d istal fragm en t. On ce in side th e m edu llary cavity, th e tip can tion len gth still requ ired plu s the one centim eter of the n ail th at
be rotated to align an d redu ce th e fractu re. On ce satisfactory w ill be left protruding. De n itive anchorage of the n ails in the
align m en t h as been ach ieved, th e rst n ail is advan ced 1–2 cm m etaphysis is accom plished by h am mer blows on the in serter or
across th e fractu re site in to th e d istal part of th e m edu llary im pactor ( Fig 6 .4 -7 ).

Fig 6 .4 -7 Prelim in ar y cu t.
Prior to n al seatin g, th e n ail is
Fig 6 .4 -6 Fractu re reduction . rst cu t, leavin g th e len gth of n ail
Th e tip of th e rst n ail en ters equ al to th e m easu red d istan ce to
th e m edu llar y can al of th e be advan ced plu s th e on e cen ti-
distal fragm en t. Th is n ail tip m eter of th e n ail th at w ill be left
can be rotated to im prove th e protru din g from th e en tran ce site.
align m en t. Note th at th e tip Th e n ail tips are th en tu rn ed
is d irected towards th e sam e backwards to create th e n orm al
cortex as th e en tran ce site. In align m en t of th e tibia; oth er w ise
add ition , th e m axim u m con - th ere is cosm etically bad recu r va-
tou r of th is n ail is located on tu re. Th e n ail tip is th en advan ced
th e side of th e apex of th e w ith th e h am m er to lie ju st prox-
wedge. im al to th e d istal ph ysis.

16 5
 6 Tib ia

3 Re d u ct io n a n d fixa t io n (co n t) 4 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Im m ed iately postoperatively, a rad iological ch eck is m ade of th e en tire lower leg to

con rm th e adequ acy of th e overall redu ction an d align m en t ( Fig 6 .4 -9 ). Follow in g
th e su rgical procedu re, th e lim b can be placed on a cu sh ion or on a foam splin t. If
th e fractu re fragm en ts h ave adequ ate bu ttressin g, n o add ition al im m obilization is
u su ally n eeded. Mobility is re-establish ed w ith active an d passive gu ided m ove-
m en ts of th e h ip, k n ee an d an kle join ts w ith ou t weigh t-bearin g. In som e cases, a
con tin u ou s passive m otion splin t (CPM) m ay be u tilized.

Partial weigh t bearin g is perm itted accordin g to th e patien t’s m otivation an d pain
sen sation . Often , th e ch ild w ill begin protected weigh t bearin g on day 2 or 3. Su b-
sequ en t weigh t-bearin g progresses as th e ch ild decides.

Fu ll weigh t-bearin g is gen erally ach ieved after 3 –4 weeks. X-rays taken at 4 weeks
often sh ow adequ ate callu s ( Fig 6 .4 -10 ). By 6 m on th s th e fractu re site h as been com -
pletely obliterated an d rem odeled to perm it n ail rem oval ( Fig 6 .4 -11 ).

Fig 6 .4 -8 Fin al position .

Th e en ds h ave been cu t leavin g 1 cm of
th e n ail en d ex posed. Th e sk in is su tu red
to cover th ese ex posed tips.

a b a b a b

Fig 6 .4 -9 a – bAP an d AP an d
Fig 6 .4 -10 a – b Fig 6 .4 -11a – b Fin al
lateral x-rays taken lateral x-rays taken h ealin g. AP an d lateral
im m ed iate postopera- at 4 weeks dem on strate x-rays taken prior to
tively sh ow w ide adequ ate callu s. n ail rem oval (6 m on th s
separation of th e n ail postoperatively) sh ow
con tou rs at th e fractu re com plete rem odelin g of
site wh ich provides th e fractu re site.
m axim u m stability.

16 6
 6 .4 Tib ia l m id s h a ft fra ct u re , w e d ge (42 t -D/ 5 .2)

5 Pit fa lls – 6 Pe a rls +

Ap p ro a ch Ap p ro a ch
Th e en tran ce can al is too steep w h ich w ill preven t con tact Less steep in sertion of th e n ail an d/or m ore extrem e pre-
between th e n ail an d th e opposite cortex. con tou rin g of th e n ail w ill en su re adequ ate con tact of th e
n ail w ith th e opposite cortex.
If th e in cision is too cran ial, th ere is a risk of in ju r y to th e
ph yseal cartilage.

Re d u ct io n a n d xa t io n Re d u ctio n a n d xa t io n
If th ere is loss of redu ction after an attem pt at closed If th ere is an y u n certain ty abou t ax ial stability, th e fol-
redu ction w ith cast im m obilization , ESIN stabilization low in g steps can be taken :
sh ou ld be u n dertaken . • Keep to sh ort in tervals between th e follow-u p x-rays for
th e du ration of n on operative treatm en t.
• Use a th icker im plan t an d/or m ore extrem e precon tou r-
in g.
• Apply a m in i extern al xator, wh ereby on ly on e
Sch an z screw is in serted at th e level of th e in tersection
proxim ally an d/or distally to in crease th e w idth of
Fig 6 .4 -12 a – b Loss of displacem en t, wh ich w ill th en in crease th e ten sion
redu ction : of th e n ails again st th e in n er cortex (th is con cept is
a AP an d discu ssed in ch apter 1.1 Biom ech an ics as “Th e m iss-a-
b lateral x-rays dem on stratin g n ail tech n iqu e” a n d illu strated in Fig 1.1-11 ).
loss of redu ction in a frac-
tu re treated con ser vatively.
Th e treatm en t requ ired a
ch an ge of m an agem en t, ie,
a b
ESIN stabilization .

If th e n ail is too th in , th ere m ay be in su f cien t stability

w h ich in creases th e risk th at th e n ail w ill ben d u n der
load.

If th e n ail is too th ick, th ere m ay n ot be en ou gh elasticity

w h ich in creases th e risk of delayed h ealin g or secon dar y
deform ity.

167
 6 Tib ia

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Re d u ct io n a n d xa tio n (co n t) Re d u ct io n a n d xa t io n (co n t)

c d

a b

a b

Fig 6 .4 -13 a – b
a AP an d
b lateral im ages of a fractu re in wh ich the n ails corrected
e f g h
the m alalign ment.
Fig 6 .4 -14 a – f
If th e n ail tw ists like a corkscrew, it w ill n ot exert
a – b AP an d lateral x-rays of a 14-year-old boy w ith a
adequ ate ten sile force on th e in tern al cortex. Th is w ill
m u ltifragm en tary lower leg fractu re.
produ ce an u n stable con d ition an d m u st be corrected.
c– d Detailed view of screw application ; it is recom m en -
ded th at a gu ide w ire is in serted rst an d th en a
Align m en t in recu rvatu re m u st also be avoided.
can nu lated screw over th e gu ide w ire.
e – f X-rays after 6 weeks sh ow good align m en t an d cor-
It is im portan t to avoid a residu al fractu re gap. Th is
rect len gth .
m ay in crease th e risk of delayed h ealin g an d possible
g– h Good con solidation after 4 m on th s, fu ll weigh t
developm en t of a lim b len gth d ifferen ce.
bearin g was allowed after 8 weeks. Nail rem oval is
plan n ed after 6 m on th s postoperatively.

If th e corkscrew ph en om en on occu rs, th ere m u st be an

im m ed iate su bstitu tion of th e n ails.

Th e n ail en ds in th e d istal fragm en t sh ou ld be orien ted in

a posterior d irection .

Apply ax ial com pression wh en perform in g th e n al re-

du ction .

16 8
 6 .4 Tib ia l m id s h a ft fra ct u re , w e d ge (42 t -D/ 5 .2)

5 Pit fa lls – (co n t) 6 Pe a rls + (co n t)

Re h a b ilit a t io n Re h a b ilit a t io n
Excessive protru sion of th e n ail en ds from th e cortex Th is can be avoided by leavin g on ly on e cen tim eter ex-
of th e proxim al fragm en t can lead to irritation of th e posed an d protectin g th e n ail en ds w ith a n ail en d cap.
overlyin g soft tissu e w ith possible sk in perforation .

16 9
 7 Spe cial indications

7.1 Pa t h o lo gica l h u m e ra l s h a ft fra ct u re (12 -D/ 5 .2) 175

7.2 Pa t h o lo gica l p ro xim a l fe m o ra l fra ct u re (31-M/ 3 .1– III) 181

7.3 Pa t h o lo gica l fe m o ra l fra ct u re (32 -D/ 5 .1) 18 7

7.4 Pa t h o lo gica l d is t a l fe m o ra l fra ct u re (3 3 -M/ 3 .1) 19 3

7.5 Co m p le x cla vicu la r fra ct u re s 19 9

7.6 Su b ca p it a l fra ct u re o f m e t a ca rp a l V 2 0 5

7.7 Ra d ia l n e ck m a lu n io n 211

7.8 Ra d ia l a n d u ln a r m a lu n io n 215

7.9 Tib ia l co rre ct io n o s t e o t o m y (u n k n o w n u n ila t e ra l b o n e m a lfo rm a t io n ) 219

170
7 Spe cial indications

1 Pa t h o lo gica l fra ct u re s

Mu lt ip le ca u s e s sis or an extern al xator m ay be n eeded to provide stability.

Path ological fractu res in ch ildh ood are n ot rare. Th e peak In add ition , som e oth er au th ors h ave recom m en ded can n u -
in ciden ce occu rs between th e age 10 an d 16 years. Th e m ost lated screw s or steroid in jection s.
com m on cau ses of th ese path ological fractu res in clu de lo-
calized lesion s su ch as ben ign bon e tu m ors an d bon e cysts. Us e o f ESIN
On rare occasion s th e tu m or m ay be m align an t. In add ition , Sin ce th e in trodu ction of th e ESIN tech n iqu e, it h as replaced
gen eralized con dition s su ch as osteogen esis im perfecta m ay or su perseded m ost of th ese previou sly u sed procedu res.
predispose th e ch ild to fractu res follow in g seem in gly m in or Wh ile th e ESIN m eth od does n ot ach ieve 100% h ealin g rates
trau m a. All th ese cau ses are frequ en tly m ade by pain . of th e bon e lesion s, th e h ealin g rate is far su perior to th at for
oth er m eth ods. Th e bon e cysts often do n ot com pletely resolve
Som e of th e possible cau ses in clu de: bu t develop su f cien t stren gth in th e su rrou n din g bon e so as
Un icam eral bon e cysts n ot to pred isposed to a recu rren t fractu re. Oth er factors su ch
Non ossifyin g brom as as localization in th e bon e, age, an d type of path ology m ay
An eu r ysm al bon e cysts in u en ce th e h ealin g rate.
Mon ostotic brou s dysplasia
En ch on drom atosis Ad va n t a ge s o f ESIN
Osteogen esis im perfecta Th e ESIN tech n iqu e provides th e follow in g advan tages in th e
Oth er rare ben ign bon e d ieases treatm en t of path ological fractu res:
Sim ple an d secu re fractu re stabilization .
Mu lt ip le t e a m a p p ro a ch Du rin g th e prolon ged h ealin g period ch arateristic of th e
Neverth eless, it is of extrem e im portan ce to an alyze th e cau se lesion s, add ition al im m obilization is u n n ecessary.
of a path ological fractu re. Th is im plies th at th ese fractu res Th u s, im m ed iate m obilization is possible
sh ou ld be referred to specialized cen ters th at h ave a team Perforation of th e m edu llary can al leads to th e relief of th e
com posed of pediatric su rgeon s, orth opedists, trau m a su r- process, particu larly th e cysts. Th is perm an en t perforation
geon s, rad iologists, an d on cologists. Th ese team s sh ou ld be of th e m edu llar y can al is accepted also cau sally for two
readily available to evalu ate th e lesion s an d form u late speci c reason s:
plan s of m an agem en t. – th e sprou t, ie, th e im m igration of th e osteoblasts is facili-
tated,
Origin a l t re a t m e n t – perm an en t decom pression facilitates bon e recon stru c-
A m u ltitu de of th erapies h ave been described in th e literatu re. tion an d h ealin g.
On e of th e m ost com m on m eth ods u sed is th e evacu ation of proph ylactic stabilization w ith th e possibility for th e h eal-
th e path ological lesion an d im paction w ith au togen ou s can - in g of th e process.
cellou s bon e. In m an y cases su pplem en tal plate osteosyn th e-

171
 7 Sp e cia l in d ica t io n s

1 Pa t h o lo gica l fra ct u re s (co n t)

Team* evaluation
of x-rays

Biopsy Biopsy con rmed ESIN can be

Suspicious benign process performed after
discussion with
Biopsy positive > the parents
de nitive treatment
Cystic for tumor initiated
lesionincidental
nding

Benign Nailing can be performed,

biopsy for diagnosis is
recommended

Biopsy Biopsy con rmed ESIN can be

Suspicious benign process performed

Biopsy positive >

Pathological de nitive treatment
Involved bone for tumor initiated
fracture
fully destroyed

Benign Nailing can be performed,

biopsy for diagnosis is
recommended

Biopsy Biopsy con rmed ESIN can be

Suspicious benign process performed

Biopsy positive >

de nitive treatment
Involved bone
for tumor initiated Ta b 7-1 Tre a t m e n t a lgo rit h m
not destroyed
but only replaced fo r p a t h o lo gica l fra ct u re s .
Mem bers an d clin ic d irectors in volved w ith th e
Benign Nailing can be AO grou p h ave developed a treatm en t algorith m
performed; biopsy for m an agin g m ost path ological fractu res. Th e
for diagnosis is aglorith m s are listed for each of th e th ree m ajor
* pediatric oncologist, radiologist, surgeon. recommended ways th at th e path ological lesion s presen t.

17 2
 7 Sp e cia l in d ica t io n s

2 Sp e cia l fra c t u re s —cla vicle

Th e vast m ajor ity of clavicu lar fractu res can be su ccessfu lly Th e in d ication s for su rgical treatm en t are as follow s:
treated by con ser vative m an agem en t. However, cases of n on - Dislocation w ith poten tial sk in perforation
u n ion an d sh orten in g of th e clavicle w ith poor cosm etic re- Sh orten in g an d/or in stability of th e sh ou lder
su lts h ave been reported even in ch ildren . Possible prolon ged m orbid ity becau se of im pin gem en t of
soft tissu e
It is clear th at a su rgical approach is n ot com m on ly in d icated Open fractu res
an d, in som e cases, th e in d ication s are n ot strictly de n ed. Neu rovascu lar com prom ise
Risk to m ed iastin al stru ctu res
As d isplaced fractu res m ain ly occu r in adolescen ts it m ay be Cosm etics
n ecessary to pay special atten tion to th e patien t’s opin ion
wh en weigh in g u p th e pros an d con s of an operation , espe- Th ere are in d ication s for th e su rgical treatm en t of clavicu lar
cially in girls w ith fractu res of th e lateral en d of th e clavicle. fractu res, bu t th ey are rare an d occu r m ain ly in older ch il-
dren . On ce su rgically treated th e resu lts are satisfactory. In
Accord in g to th e literatu re m idth ird fractu res are th e m ost ou r opin ion , th e best treatm en t m eth od is in m ost cases is
com m on in ch ild ren , followed by fractu res of th e lateral en d. elastic stable in tram edu llary n ailin g.

3 Sp e cia l fra ct u re s —m e t a ca rp a l

Alm ost 10% of all fractu res in ch ild h ood affect th e bon es of In ou r opin ion , u n stable, in su f cien tly redu cible, in traar ticu -
th e h an d. 72 (21.6% ) of th e 332 fractu res of th e h an d diag- lar, m u ltiple fractu res of th e m etacar pals, possibly open frac-
n osed at ou r clin ic were m etacar pal fractu res, wh ereby th e tu res as well, are in d ication s for in tern al xation . Th e m ajor-
rst an d fth m etacar pal bon es were affected in th e m ajority ity can be treated in closed tech n iqu e.
of cases.
As for th e lon g bon es, th e sam e degree of su ccess can be
Alth ou gh fractu res of th e m etacar pu s in ch ildren can alm ost ach ieved h ere w ith ESIN tech n iqu e. Especia lly n e n ails or
always be treated w ith ou t su rgery, th ere are speci c in dica- K-w ires are u sed. Sin ce th e m ajority of th ese fractu res are
tion s for an operative procedu re. su bcapital fractu res, th e tech n iqu e is equ ivalen t to th at for
th e redu ction an d xation of th e rad ial h ead.
In pr in ciple, th ere are th ree m ain issu es relevan t to su rgical
redu ction :
1. Wh ere is th e m ain deform ity an d w h at w ill be th e resu lt of
a poten tial correction procedu re?
2. Is th ere rotation deform ity?
3. Wh at w ill be th e effects of a residu al deform ity in term s of
fu n ction an d cosm esis?

17 3
 7 Sp e cia l in d ica t io n s

4 Su gge s t e d re a d in g

Cap an n a R , Cam p an acci DA , Man frin i M (1996) Ro p o sch A , Sarap h V, Lin h art WE (2000)
Un icam eral an d an eu rysm al bon e cysts. Flexible in tra m edu llar y n ailin g for th e treatm en t
Orthop Clin North Am; 27(3):605 –614. of u n icam eral bon e cysts in lon g bon es.
Cat ie r P, Bracq H , Can cian i J P, e t al (1981) J Bone Joint Surg Am; 82-A(10): 14 47–1453.
[ Th e treatm en t of u pper fem oral u n icam eral bon e cysts San t o ri F, Gh e ra S, Cast e lli V (1988)
in ch ild ren by En der‘s n ailin g tech n iqu e]. Treatm en t of solitary bon e cysts w ith in tram edu llar y
Rev Chir Orthop Reparatrice Appar Mot; 67(2):147–149. n ailin g.
Cam p an acci M , Cap an n a R , Picci P (1986) Orthopedics; 11(6):873 –878.
Un icam eral an d an eu rysm al bon e cysts. Wilk in s R M (2000) Un icam eral bon e cysts.
Clin Orthop Relat Res; (20 4):25 –36. J Am Acad Orthop Surg; 8(4):217–224.
Im h au se r G (1968)
[Man agem en t of ju ven ile bon e cysts u sin g in tram edu llar y
n ailin g?].
Z Orthop Ihre Grenzgeb; 105(3):110 –111.

174
7.1 Pathological hum e ral shaft fracture (12-D/ 5.2)

1 Ca s e d e s crip t io n

A 14-year-old m ale was in volved in a m in or collision w ith a

sch oolm ate wh ich resu lted in in ju r y to h is righ t arm . X-rays
of th e hu m eru s dem on strated a large lytic lesion in th e
m idd iaph ysis. In its d istal portion , th e lesion con tain ed a
spiral fractu re w ith an associated free wedge segm en t. Clin i-
cally, th is fractu re appeared to be u n stable.

Fig 7.1-1a – b Lateral an d AP x-rays of th e hu m eru s dem on -

stratin g a large cystic lesion w ith a m u ltifragm en tar y fractu re
pattern an d m in im al sh orten in g.

As s e s s m e n t o f th e p a th o lo gy
A team con sistin g of a pediatric su rgeon , ped iatric on cologist,
an d a ped iatr ic rad iologist wh o agreed th at th e lesion appeared
to be ben ign evalu ated th ese x-rays. Th ere were n o m align an t
ch an ges. Th e lesion was felt to be con sisten t w ith a u n icam -
a b
eral bon e cyst (see Ta b 7-1).

2 In d ica t io n

Th is fractu re m et th e criteria for su rgical in terven tion becau se:

It was a very u n stable fractu re.
Con servative m an agem en t wou ld requ ire a lon g period of im m obilization .
Fractu res th rou gh th ese lesion s are often slow to h eal an d becom e stable.
Usu ally, secon dary treatm en t is n ecessary to resolve th e cyst.
A biopsy m ay be n ecessary to con rm th e diagn osis of th e lesion .

175
 7 Sp e cia l in d ica t io n s

3 Su rgica l a p p ro a ch

Th e stan dard ESIN tech n iqu e for d iaph yseal an d prox im al

hu m eral sh aft fractu res is via a u n ilateral radial or lateral
an tegrade approach . Th is case presen ts a lon g fractu re zon e
wh ich is very d if cu lt to stabilize.

In cases su ch as th ese th e so-called con ven tion al d istal retro-

grade tech n iqu e w ith bilateral en tran ce sites is recom m en ded
becau se it provides better 3-poin t con tact to ach ieve stability.
Th is is often referred to as th e “Tou r d’Eiffel” con stru ction .

Re tro gra d e a d va n t a ge s
An oth er advan tage of a bilateral in sertion tech n iqu e is th at
th e n ails are m u ch easier to m an ipu late, wh ich lessen s th e
ch an ce of fu rth er in ju ry to th e th in cortex. Th e lateral in ci-
sion is perform ed in th e u su al m an n er.

Fig 7.1-2 Th e ideal xation w ith sym -

m etrical bracin g of th e fractu re by th e
n ails is dem on strated in th is x-ray.

In cis io n s
On th e u ln ar side, great care m u st be taken to avoid in ju ry to
th e u ln ar n er ve. It is recom m en ded th at a large en ou gh in ci-
sion be m ade to provide d irect visu alization of th e n erve.

Th e rad ial in cision starts over th e lateral con dyle an d ru n s for

3 –4 cm prox im ally.

Distally, th e rad ial aspect of th e d istal hu m eru s is ex posed by

blu n t d issection dow n to th e periosteu m . Th e ex posed perios-
teu m is th en in cised to facilitate su bperiosteal position in g of
th e h ook of th e Hoh m an n retractor an teriorly. Th is provides
d irect visu alization of th e lateral aspect of th e d istal h u m eru s
via a 2 ×3 cm bon e w in dow. Th e lateral en tran ce site is created
w ith an aw l or d rill. It is im portan t to lower th e drill to 45º
on ly wh en th e drill is ru n n in g to preven t breakage of th e tip.
Fig 7.1-3 It is ver y im portan t to protect th e u ln ar n er ve for
th e u ln ar approach .

176
 7.1 Pa t h o lo gica l h u m e ra l s h a ft fra ct u re (12 -D/ 5 .2)

3 Su rgica l a p p ro a ch (co n t)

On th e u ln ar side, a lon ger in cision is u tilized. To m in im ize

th e risk of delayed in ju ry to th e u ln ar n erve by th e n ail th is
in cision is placed in a m ore an terior location on th e arm . Per-
foration of th e u ln ar cortex is perform ed in th e sam e m an n er
as on th e lateral aspect. However, becau se of th e n arrow aspect
of th e u ln ar su pracon dylar ridge, extrem e care sh ou ld be u sed
w h en perforatin g th e cortex.

Fig 7.1-4 Th e en tr y poin t on th e lateral side is

created as u su al.

4 Re d u ct io n a n d fixa t io n

Avo id p e rfo ra t io n Fin a l s e a lin g

Th e n ail is advan ced prox im ally in th e u su al m an n er. Wh ile On ce th e n ail h as advan ced a su f cien t d istan ce in to th e prox-
th e redu ction m ay n ot be d if cu lt, care n eeds to be taken im al fragm en t, th e n ail is cu t ou tside th e bon e. Th e rem ain in g
wh en advan cin g th e n ail to avoid creatin g a secon dary frac- d istan ce to th e prox im al m etaph ysis m u st be con sidered in
tu re. Preben d in g th e n ail so th at th e tip does n ot perforate th e determ in in g w h ere to cu t th e n ail. It is best to leave abou t on e
bon e is recom m en ded. cen tim eter protru d in g from th e bon e wh en th e n ail is n ally
seated.
Na il in s e rtio n
Th e n ail is advan ced 2 –3 cm prox im ally beyon d th e fractu re Th e n al position of th e n ail is ach ieved by th e u se of th e
zon e to in su re good stability. In trodu ce a sim ilar preben t n ail beveled tam p.
on th e u ln ar side in th e sam e m an n er. Again , th e n ail m u st be
advan ced very carefu lly past th e fractu re zon e. Bio p s y a t th e s t a b iliza tio n
Becau se th e n ails w ill m ost likely rem ain in th e bon e for a
lon g tim e, th e tips sh ou ld be placed very close to th e bon e.
On ce adequ ate stabilization h as been ach ieved, a sm all in ci-
sion al biopsy is perform ed.

17 7
 7 Sp e cia l in d ica t io n s

4 Re d u ct io n a n d fixa t io n (co n t)

Fig 7.1-5 Nail in sertion . Both n ails are

very carefu lly advan ced past th e fractu re Fig 7.1-6 a – bIdeal position in g. AP an d lateral x-rays
zone. The arrow s dem on str ate direction im m ed iate postoperative. Th e n ails were position ed
of passage in retrograde tech n iqu e. to provide th e desired align m en t an d stabilization .

5 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Postoperative pain sh ou ld be m an aged appropr iately. Th is is

u su ally th e n orm al progression of th e postoperative cou rse.
Th e postoperative x-rays sh ou ld sh ow an atom ical redu ction
an d adequ ate stability to allow early m ovem en t.

If after 2 m on th s su f cien t callu s is visible an d th e cyst is

resolvin g, th e patien t m ay retu rn to n orm al sports activities.

After 1 year, th e cyst sh ou ld be alm ost com pletely h ealed.

Fig 7.1-7a – bAP an d AP an d lateral

Fig 7.1-8 a – b
lateral x-rays at 2 m on th s x-rays 1 year postoperative.
postoperative.

178
 7.1 Pa t h o lo gica l h u m e ra l s h a ft fra ct u re (12 -D/ 5 .2)

6 Pit fa lls – 7 Pe a rls +

Ap p ro a ch Ap p ro a ch
Th e n ails h ave m igrated in side th e bon e becau se th ey After th e rst path ological fractu re, th e fractu re m ay h eal
were cu t too sh ort. w ith con ser vative treatm en t if it is relatively n on d isplaced
an d stable.
In cases in volvin g bon e cysts, th e n ails m ay rem ain in th e
bon e for a lon g tim e, allow in g th e en ds of th e n ails to
becom e overgrow n w ith callu s.

b c

Fig 7.1-10 a – c Non operative treatm en t. Sin ce th is path o-

logical fractu re of th e prox im al h u m eru s was stable an d
n on d isplaced, it was m an aged n on operatively.
a Acu te fractu re.
Fig 7.1-9 a – d
b 2 m on th s postfractu re.
a – b Nails wh ich stay lon ger th an 2 years in th e bon e can -
c 4 m on th s postfractu re.
n ot be rem oved in m ost cases. At th e attem pt to
rem ove th ese n ails a great dam age to th e bon e arises
Th is cyst persisted an d con tin u ed to grow. It fractu red a
an d th e n ails break off.
secon d tim e an d was again m an aged con ser vatively.
c– d After on e year m ore th e n ails are com pletely over-
grow n by bon e.
With th e occu rren ce of a th ird fractu re, ESIN stabilization
Th e rad ial or u ln ar n erves can be irritated eith er du rin g was in d icated. Su bsequ en t biopsy revealed th is lesion to
n ail in sertion or by leavin g th e u ln ar n ail protru din g too be an an eu rysm al bon e cyst wh ich m ay h ave accou n ted
m u ch . for th e persisten ce of th e lesion .

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
In correct placem en t of th e n ail can produ ce in adequ ate Lateral radial in cision . If th e cyst an d fractu re are proxi-
stabilization . m al, th en both n ails can be in serted th rou gh a sin gle
d istal lateral in cision w ith separate cortical en tran ce sites.
If th e n ails are too sh ort, th e cyst m ay n ot h eal an d th u s a
refractu re m ay occu r at th e level of th e n ail tip. Proxim al lateral in cision . Th e redu ction an d xation are
ach ieved u sin g th e con ven tion al m on olateral tech n iqu e
via a sin gle prox im al lateral in cision an d separate cortical
en tran ce sites.

179
 7 Sp e cia l in d ica t io n s

6 Pit fa lls – (co n t) 7 Pe a rls + (co n t)

Re d u ct io n a n d xa t io n (co n t) Re h a b ilit a t io n
Postoperative recovery u su ally in volves straigh tforward,
pain less m obilization . Th e h ealin g of th e fractu re
an d redu ction of th e cyst sh ou ld occu r w ith in 3 m on th s.
Com plete resolu tion of th e cyst sh ou ld be presen t by
3 years. Bon e grow th is eviden ced by observin g an in -
crease in th e d istan ce from th e tip of th e n ails to th e
physis. Un less th ey are both ersom e, th e n ails n eed n ot
rem oved.

Fig 7.1-12 a – c
Fig 7.1-11a – f Refractu re. a Follow in g th is secon d
a – b Fou r years previou sly, th is 16-year-old m ale h ad fractu re, ESIN stabiliza-
u n dergon e ESIN stabilization follow in g a fractu re tion was perform ed.
th rou gh an an eu rysm al bon e cyst. Un fortu n ately, A biopsy taken at th e
th e cyst persisted an d a n ew fractu re occu rred. tim e of th e stabilization
c– d As part of th e treatm en t it was origin ally plan n ed to con rm ed th e d iagn osis
replace both n ails. However, on ly on e n ail cou ld be of an an eu rysm al bon e
rem oved. As can be seen , th ere was con siderable cyst.
dam age to th e cyst wall w h ich requ ired in sertion of b X-ray at 4 m on th s.
bon e cem en t for added stability. c At 1 year.
e – f Com plete h ealin g of th e cyst cou ld be seen 14
m on th s after th is com bin ed m edical treatm en t.

Re h a b ilit a t io n
Despite appropriate treatm en t th e cyst m ay con tinu e
to grow even w ith th e n ails rem ain in g in place.
Fig 7.1-13 a – b Com plete resolu tion .
AP an d lateral x-rays of th e
Even after com plete h ealin g, th e cyst m ay recu r years
com pletely h ealed cyst of th e patien t
later.
3 years post ESIN stabilization .
Th e h u m eru s h as con tinu ed to
Th e cyst m ay fail to com pletely resolve.
rem odel an d grow. Nail rem oval is
n ot plan n ed.

18 0
7.2 Pathological proxim al fe m oral fracture (31-M/ 3.1-III)

1 Ca s e d e s crip t io n

A 6-year-old boy fell wh ile playin g at h is k in dergarten . Th ere was th e im m ed iate

on set of pain , swellin g, an d deform ity in h is righ t th igh . Wh en evalu ated in th e
em ergen cy room , x-rays sh owed a severe, d isplaced fractu re of th e proxim al fem u r
( Fig 7.2 -1 ). In itially, it was u n clear w h eth er th is in volved th e lateral n eck or tran s-
troch an teric region of th e fem u r. Th e rst im pression was th at th is fractu re was
th rou gh a large u n icam eral bon e cyst.

De te rm in a tio n o f t h e p a th o lo g y
In th e rst evalu ation , becau se of th e large displacem en t an d an gu lation , it was very
d if cu lt to arrive at a clear d iagn osis. Th e case was evalu ated by a team com posed
of a pediatric su rgeon , a ped iatric on cologist, an d a ped iatric rad iologist. Based u pon
th e absen ce of an y periosteal reaction or sign s ch aracter istic of m align an cy, th is
Fig 7.2 -1 In itial x-ray sh ow in g a d is- in terd isciplin ar y team determ in ed th at th e d iagn osis was clearly th at of u n icam eral
placed fractu re th rou gh a lytic lesion of bon e cyst. However, becau se of its localization , an altern ative d iagn osis was th at of
th e prox im al righ t femu r. an an eu rysm al bon e cyst.

2 In d ica t io n 3 Su rgica l a p p ro a ch

As th ere appeared to be n o con train d i- De cis io n fo r ESIN

cation s, it was felt th at su rgical stabiliza- Th e determ in ation of th e appropriate su rgical procedu re to m an age th is fractu re
tion was th e best m eth od of treatm en t. in volves a con sideration of variou s factors. Th e fractu re was very prox im al an d was
Th e follow in g is a list of th e prim ary su rrou n ded by poor qu ality bon e. Th is carried th e risk of collapse an d sh orten in g.
in d ication s for th e su rgical m an age- Stabilization of th e fractu re w ith an an gled blade plate or lon g screw s was n ot able
m en t: to provide th e stability n eeded.
Th is appeared to be an extrem ely
u n stable fractu re. Wh en th ese factors were con sidered, th e best solu tion appeared to be th e ESIN tech -
It was an ticipated th at th e h ealin g n iqu e.
tim e wou ld be prolon ged.
Becau se of th e in stability of Ad va n t a ge s
th e fractu re, th e im m obilization Th e m ain advan tage of ESIN is to provide stability w ith m in im al invasiven ess. In
tim e was pred icted to be lon g if add ition , it h as been th e experien ce of th e AO ped iatric su rgeon s grou p th at wh en
treated con ser vatively. ESIN is u sed, su pplem en tal bon e graftin g h as alm ost n ever been requ ired.
Th ere also n eeded to be som eth in g
in th e treatm en t m eth od to stim u -
late resolu tion of th e pr im ary
lesion .
181
 7 Sp e cia l in d ica t io n s

3 Su rgica l a p p ro a ch (co n t)

Pa t ie n t p o s it io n in g
Th e ch ild is placed in a free position on th e table. A folded
sh eet w rapped arou n d th e groin of th e u n affected lower 3
extrem ity secu res th e patien t to th e su rgical table (see Fig 5 .1-1). 1 2
Th is also provides cou n ter traction . Th e h ip mu st be su f -
cien tly u n obstru cted to be able to obtain good im ages w ith th e
in ten si er. It is im perative to h ave free rotation of th e leg.
Preoperatively, th e clin ical rotation of th e n on fractu red side
m u st be m easu red an d docu m en ted. In som e patien ts, it m ay
also be advan tageou s to su rgically prepare both legs to pro-
vide a better clin ical evalu ation .

Th re e -n a il co n gu ra t io n
In stead of th e n orm al two n ails, th ree n ails are u sed w ith th is
fractu re pattern . Th is extra n ail, wh en u sed appropriately,
provides th e n ecessary su pport for th is fractu re. Th e sh ort Fig 7.2 -2 Th ree-n ail xation .
proxim al fragm en t is su pported like a ball on th ree n gers. A sch em atic draw in g dem on stratin g th e ideal position of th e
Th e rst n ail is an ch ored in th e greater troch an ter. Th e secon d tips of th e th ree n ails in th e prox im al fem u r. Th e two laterally
n ail is directed in to th e cran ial aspect of th e fem oral n eck. Th e in serted n ails are advan ced to th e su perior n eck an d greater
th ird n ail is d irected towards th e ph ysis of th e fem oral h ead troch an ter. Th e th ird n ail is in serted m ed ially to en ter th e
( Fig 7.2 -2 ). cen ter of th e fem oral n eck.

Me d ia l-la te ra l e n tra n ce s ite s

To obtain th e desired stability, th e th ree n ails m u st be in serted
from two separate lateral en tran ce sites an d a sin gle m ed ial
en tran ce site. Th e lateral in cision sh ou ld be a little lon ger th an
n orm al. Each of th e n ails is advan ced as for th e n orm al retro-
grade n ailin g tech n iqu e.

4 Re d u ct io n a n d fixa t io n

Ge n e ra l co n s id e ra t io n s
Th e redu ction of su ch prox im al fractu res is n ot as d if cu lt as
it wou ld in itially appear.
It is im portan t to accu rately pre-con tou r th e n ails, especially
in th e portion th at w ill u ltim ately lie w ith in th e fractu re zon e.
Con tinu ou s traction on th e extrem ity is advisable becau se of
th e u n stable n atu re of th e fractu re.

18 2
 7.2 Pa t h o lo gica l p ro xim a l fe m o ra l fra ct u re (31-M/ 3 .1-III)

4 Re d u ct io n a n d fixa t io n (co n t)

La te ra l e n tra n ce s ite s Avo id co rte x p e n e t ra t io n

Th e lateral in cision sh ou ld be a little lon ger th an u su al becau se Becau se th e lesion is ver y large, th e su rgeon m u st advan ce
of th e n eed to adequ ately split th e fascia lata an d provide th ese rst two n ails very carefu lly so as n ot to perforate th e
separate en tran ce sites. Th e rst n ail is in serted follow in g proxim al cortex w ith th e n ail. It is essen tial to ch eck th e
perforation of th e lateral cortex at th e u su al en tr y poin t for align m en t of th e fractu re as well as th e d irection of th e n ail at
retrograde n ailin g. Th is n ail (1) is th en advan ced to th e frac- all tim es w ith th e im age in ten si er w h en m an ipu latin g th e
tu re zon e. At th is poin t, th e tip is th en rotated towards th e n ail tip in th e fractu re zon e.
greater troch an ter. It is th en driven in to th e su bstan ce of th e
greater troch an ter to obtain prelim in ar y xation ( Fig 7.2 -3 a ). Me d ia l e n tra n ce s ite
An in cision is m ade on th e m ed ial side an d th e cortex is
To prevent splittin g of the bone, a second lateral entrance site is pen etrated in th e u su al m an n er as for rou tin e retrograde
m ade 1–2 cm more proxim al and 1 cm more anterior. The second n ailin g. Th is well-con tou red n ail (3) is then advan ced proxi-
precontou red n ail (2) is then advanced up to the fractu re zone m ally to th e fractu re zone directin g it toward th e center of th e
towards the su perior aspect of the femoral neck ( Fig 7.2-3b ). Th is physis ( Fig 7.2-3c). With th is th ird n ail, it is im portan t to be care-
n ail ch aracteristically h as two contou rs (S-sh ape). fu l th at th e n ail does n ot pen etrate th e cortex at th e calcar.

1 1 2 2 3 Fig 7.2-3a – d Step-by-step

1
procedu re.
a Follow in g fractu re redu c-
tion , prelim in ary xation
is ach ieved by rst advan c-
in g n ail 1 prox im aly to th e
greater troch an ter from
th e rst lateral en tran ce site.
b Nail 2 is advan ced prox i-
m ally to th e cyst from
a secon d lateral en tran ce
2 poin t. Notice th at it h as two
3 con tou rs (S-sh ape).
1 c Nail 3 is in serted from a
2 m edial en tran ce site to be
18 0 ° 1 secu red in th e fem oral n eck
or h ead. At th is poin t, th e
1 de n itive redu ction an d
a b c xation h as been ach ieved.

18 3
 7 Sp e cia l in d ica t io n s

4 Re d u ca t io n a n d fixa t io n (co n t)

Fin a l im p la n t a tio n Fin a l a s s e s s m e n t

Traction is then applied to the extrem ity and n ail #3 is advanced On ce th e th ree n ails h ave been seated in th eir n al position s,
proxim ally into its de n itive position in the femoral neck ju st a n al evalu ation of th e stability of th e fractu re is m ade. It is
short of the physis. It is im portant at th is point to check th at the also im portan t to ch eck th e rotation al align m en t ( Fig 7.2 -4 )
femoral neck is reduced de n itively in reference to varu s, valgu s,
and rotation al align ment. If necessary, the physis of the proxi- It is in terestin g to n ote th at a biopsy of th is lesion determ in ed
m al femu r can be perforated once to ach ieve better anchorage. it to be an an eu rysm atic bon e cyst.
Prior to the n al seatin g of the n ail 3, it is im portant to cut the
n ail to the correct length . The n al step in ach ieving th is th ree
n ail stability involves advancing n ail 2 proxim ally into the supe-
rior femoral neck ( Fig 7.2-3d ).

1 2 3

2 3
1

d a b

Fig 7.2 -3 a – d (co n t) Step-by-step procedu re. Th e postoperative AP an d

Fig 7.2 -4 a – b
d Fin al im plan tation . All th ree n ails h ave lateral x-rays dem on strate both a good
been secu red in th eir n al position s pro- redu ction of th e fractu re an d satisfac-
vid in g su f cien t stability to allow partial tory position in g of th e n ails.
weigh t bearin g.

18 4
 7.2 Pa t h o lo gica l p ro xim a l fe m o ra l fra ct u re (31-M/ 3 .1-III)

5 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Adequ ate pain m an agem en t is im portan t. By th e n ext ou t-patien t visit at 3 m on th s, th e patien t h ad clin -
ically ach ieved a free ran ge of m otion w ith equ al in tern al an d
In it ia l m o b iliza tio n extern al rotation ( Fig 7.2 -6 ). Th ere was sh orten in g of on ly 1
For th e rst 3 days th e ch ild rem ain s in bed. On day 4 m obili- cm at th e fractu re site. X-rays taken at th is tim e dem on strated
zation w ith a physioth erapist is in itiated allow in g on ly a toe n early com plete h ealin g an d rem odelin g ( Fig 7.2 -7 ). Fu ll sports
touch gait. By day 8 th e patien t can u su ally be disch arged from activities were allowed. Nail rem oval was perform ed at 8
th e h ospital h avin g ach ieved free m obilization on cru tch es. m on th s.

Ou tp a tie n t fo llo w -u p Fu ll re co ve r y
Th e rst ou t-patien t visit is u su ally at abou t 6 weeks. Th e By th e n al visit occu rrin g two years post fractu re th ere was
x-rays taken th en sh ou ld dem on strate good h ealin g an d callu s fu ll rem odelin g w ith essentially a norm al femu r on th e x-rays
( Fig 7.2 -5 ). Fu ll weigh t bearin g sh ou ld be ach ieved by week 8. ( Fig 7.2-8 ). Th e leg len gth discrepan cy h ad disappeared.

Fig 7.2 -6 a – b Clin ical recover y. Clin ically, at 3 m on th s th e patien t h ad a

n orm al ran ge of m otion dem on stratin g equ al an d ( a ) n orm al in tern al
an d ( b ) extern al rotation .

AP an d lateral x-rays after 6 weeks

Fig 7.2 -5 a – b
dem on strate good callu s form ation an d sign s of
early cyst resolu tion .

Fig 7.2 -7a – b AP an d lateral Fig 7.2 -8 a – bCyst resolu tion .

x-rays after 3 m on th s AP an d lateral x-rays at th e last ou t-
dem on stratin g n early com plete patien t visit w ith fu ll rem odelin g of
h ealin g of th e fractu re. th e fractu re an d resolu tion of th e cyst.

18 5
 7 Sp e cia l in d ica t io n s

6 Pit fa lls – 7 Pe a rls +

Ap p ro a ch Ap p ro a ch
Makin g th e lateral in cision too sm all cau ses th e in sertion If th e redu ction is adequ ate, ESIN can provide good
tools to exert u n du e pressu re on th e sk in . Th is can resu lt xation .
in sk in n ecrosis an d in fection .
It is best to perform th e open biopsy rst as th is
allow s th e redu ction of th e fractu re to be perform ed
u n der d irect vision .
Fig 7.2 -9 If th e ch ild is
position ed im properly, th ere
m ay n ot be a clear im age Re d u ctio n a n d xa t io n
w ith th e in ten si er.
Fig 7.2 -10 For path ological fractu res in
m etaph yseal region s, stability can be
Failu re to m easu re an d record th e rotation of th e u n in -
en h an ced by perforatin g th e su per ior or
ju red extrem ity preoperatively m ay resu lt in rotation al
in ferior aspect of th e ph ysis of th e
m alalign m en t follow in g stabilization of th e fractu re.
proxim al femu r w ith th e tips of th e n ails.
Th e pictu re sh ow s a case after ch ron os
in ject application in a path ological
Re d u ct io n a n d xa t io n
fractu re.
Th e ch ild is poorly position ed w h ich m ay preven t ade-
qu ate evalu ation of th e en tire fractu re.
If care is n ot taken du rin g th e in sertion process, th e n ails
can easily pen etrate th e th in cortex of th e cyst.

Th e n ail m ay leave th e fractu re zon e at th e level of th e

cyst an d advan ce ou tside th e bon e in to th e soft tissu es.
Fig 7-2 -11 Th e in n er bracin g of th e n ails
Th e n ails are n ot placed or con tou red appropriately in
can be im proved to provide greater
th e fractu re zon e to produ ce adequ ate stability.
stability by th e u se of a screw. Th is h as
been described previou sly in ch apter
1.1 Biom ech an ics as th e so-called “m iss-
a-n ail” tech n iqu e.

Re h a b ilit a t io n Re h a b ilit a t io n
If th e ESIN con stru ct is n ot correct, th e stability m ay Wh ile n ot as stable as ESIN for fractu res in n orm al bon e,
be in adequ ate an d addition al extern al im m obilization th is con stru ct is su f cien tly stable w ith th ese path o logical
w ill be requ ired. fractu res to allow im m ed iate m obilization .

Th e fractu re h eals adequ ately bu t th e cyst fails to resolve. As a resu lt, an add ition al spica cast is n ot n ecessar y.

18 6
7.3 Pathological fe m oral fracture (32-D/ 5.1)

1 Ca s e d e s crip t io n

Follow in g a rath er m in im al fall at h om e, th is 3-year-old girl Th e rad iograph ic appearan ce h ad ch an ged con siderably. It
developed su dden on set of pain an d swellin g in h er left th igh . h ad developed in to a large cystic lesion wh ich h ad pen etrated
Her x-rays were reported to dem on strate th e presen ce of a th e cortex w ith a large ossi ed portion situ ated ou tside th e
n on speci c path ological fractu re ( Fig 7.3 -1). Th e on ly treat- in tertroch an teric area. Un fortu n ately, th ere were n o follow-
m en t th at h ad been perform ed was to place h er in a spica cast u p x-rays after th e in itial fractu re to determ in e h ow it h ad
for 6 weeks. progressed. Becau se of th is situ ation , th e evalu atin g team felt
a biopsy was m an dator y. Prior to th e biopsy, a fu ll clin ical
Accord in g to th e origin al records of h er prim ar y treatm en t, it tu m or screen in g exam in ation , in clu d in g x-rays of th e th orax
was stated th at th e fractu re wen t on to h eal. Th ere was n o an d th e appropriate blood tests, was perform ed.
docu m en tation of an y follow-u p x-rays.
Th e b io p s y re s u lt
Se co n d e p is o d e Becau se of th e large am ou n t of n ew bon e form ation , arrivin g at
Eigh t m on th s later, sh e again developed acu te pain an d swell- the h istological diagnosis was very dif cu lt. The n al decision
in g in th e left th igh . X-rays were reported to dem on strate a was th at th is represen ted an atypical an eu rysm al bone cyst.
large cystic lesion in th e proxim al left fem u r ( Fig 7.3 -2 ).

a b a b

Fig 7.3 -1a – bIn itial fractu re. AP an d lateral x-rays of th e left Secon d presen tation . AP an d lateral prebiopsy
Fig 7.3 -2 a – b
proxim al fem u r dem on strate an essen tially u n d isplaced path - x-rays taken 8 m on th s later dem on strate a path ological frac-
ological fractu re th rou gh a cystic lesion . Th ere was n o dou bt tu re.
abou t th e ben ign e n atu re of th e lesion .
18 7
 7 Sp e cia l in d ica t io n s

2 In d ica t io n s

Th e in d ication s for su rgical in ter ven tion : With ou t su rgical in terven tion a lon g im m obilization tim e
Th is represen ted an extrem ely u n stable fractu re. Th ere was also pred icted.
was a sign i can t risk of a n ew, even greater fractu re resu lt- Th ere n eeded to be som e stim u lu s to resolve th e prim ar y
in g in severe loss of bon e len gth . cyst du r in g fractu re h ealin g.
It was estim ated th e h ealin g tim e of th is cyst wou ld be ver y Th e bu lk of th e tu m or m ass wou ld n eed to be redu ced.
lon g.

3 Su rgica l a p p ro a ch

It was dem on strated in th e previou s case (ch apter 7.2 Path o- th at th is fractu re w ill requ ire th ree n ails for stabilization
logical prox im al fem oral fractu re) th at th e ESIN tech n iqu e ( Fig 7.3 -3 ). Th ese n ails are in serted retrograde, u sin g two
can be u sed to stabilize path ological fractu res of th e fem u r. In lateral an d on e m ed ial en tran ce poin ts ( Fig 7.3 -4 ).
th is ver y you n g ch ild w ith good h ealin g an d rem odelin g
poten tial, th e ESIN tech n iqu e can be expected to produ ce A week after th e biopsy was perform ed to establish th e d iag-
good resu lts in both stabilizin g th e fractu re an d stim u latin g n osis, th e de n itive operative procedu re was perform ed. Du r-
th e resolu tion of th e cyst. in g th is in terval, th e extrem ity was m ain tain ed in traction .

Th re e p in s re q u ire d It h as been th e experien ce of th e AO ped iatric su rgeon s th at,

Th e prox im al location of th e fractu re zon e exten d in g from w h en u sin g th is tech n iqu e, su pplem en tal bon e graftin g to
th e base of th e n eck to th e su btroch an teric process d ictates adequ ately h eal th e cyst is alm ost n ever requ ired.

3
2 1

Fig 7.3 -3Th ree-n ail xation . Fig 7.3 -4En try poin ts.
Dem on stration of th e ideal position in g of th e th ree n ails, on e Location of th e two lateral an d th e m ed ial en try poin ts. Th e
from m edial an d two from lateral are n ecessar y to provide m ore proxim al of th e lateral en tran ce poin ts (arrow) is situ -
m axim u m stability. ated m ore on th e an ter ior aspect of th e femu r.

18 8
 7.3 Pa t h o lo gica l fe m o ra l fra ct u re (32 -D/ 5 .1)

4 Re d u ct io n a n d fixa t io n

Sin ce th e exact tech n iqu e of stabilization h as been described

in great detail in th e previou s ch apter (see Fig 7.2 -3 ), on ly a
brief ou tlin e of th e steps w ill be repeated h ere ( Fig 7.3 -5 ).

1 2 1 3 2 1 3 2 1

2
3 3 2
1 1
2
18 0 ° 1
1

a b c d

Fig 7.3 -5 a – d
a Make th e lateral in cision a little lon ger th an n orm al to c Make th e m ed ial in cision an d in sert th e th ird well pre-
allow for two en tran ce poin ts. First in sert th e n orm ally ben t n ail from its m edial in sertion poin t. Th e proxim al
precon tou red n ail as u su al an d advan ce it proxim ally part m u st be precon tou red m ore th an n orm al becau se th e
to secu re th e tip ju st below th e apoph ysis of th e greater tip h as to advan ce to th e in fer ior portion of th e prox im al
troch an ter. fem oral ph ysis.
b Next, advan ce th e secon d n ail from a secon d lateral d On ce the desired align m en t h as been ach ieved, advan ce th e
en tran ce poin t so th at th e tip reach es th e prox im al aspect n ails to th eir de n itive position s an d cu t th e distal en ds
of th e fem oral n eck. ou tside th eir respective cortices at th e distal m etaph ysis.

18 9
 7 Sp e cia l in d ica t io n s

4 Re d u ct io n a n d fixa t io n (co n t)

Before term in atin g th e an esth esia, th e rotation at th e h ip is

evalu ated. Th e ax ial stability is assessed by th e application of
gen tle blow s again st th e exed k n ee. Th ere sh ou ld n ot be an y
sign i can t ch an ge in th e ax ial align m en t of th e n ail wh en
th ese blow s are applied. Th e n al x-ray sh ou ld dem on strate
th e ideal placem en t of th e n ail tips in th e prox im al fragm en t
( Fig 7.3 -6 ).

Fig 7.3 -6 a – bFin al n ail im plan tation .

Postoperative x-rays wh ich dem on strate a satisfactory redu c-
tion alon g w ith ideal position in g of th e th ree n ails.

5 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Postoperatively, adequ ate pain m an agem en t is im portan t. Fu ll re co ve r y

Du rin g th e rst 3 days th e ch ild rem ain s in bed. A n al ou t-patien t visit u su ally occu rs at 2 years after th e
Mobilization is in itiated u n der th e close su per vision of a ph ys- operation . In add ition to com plete rem odelin g seen on th e
ioth erapist from day 4, startin g on ly w ith n orm al sittin g. x-rays ( Fig 7.3 -9 ), th ere sh ou ld be fu ll clin ical recovery w ith
A ch ild of th is age is too you n g to m obilize w ith cru tch es. n orm al in tern al an d extern al rotation of th e h ips. Th e leg
In a case su ch as th is, th e ch ild is allowed to get ou t of bed len gth s, likew ise, sh ou ld be equ al.
wh en it is ready. Th is is u su ally wh en th ey h ave little or n o
pain .

Po s th o s p it a l p h a s e
Hospital d isch arge u su ally occu rs at arou n d day 9 by wh ich
tim e th e ch ild sh ou ld h ave free m obilization .

It is u su al to h ave th e m oth er report at 6 weeks th at th e ch ild

is ru n n in g freely. Th erefore, th e rst ou t-patien t visit n eed n ot
be u n til 3 m on th s postoperative by w h ich tim e h ealin g of
both th e fractu re an d cyst sh ou ld be presen t ( Fig 7.3 -7 ). Th e
ch ild sh ou ld also be walk in g w ith ou t a lim p by th is tim e.

Arou n d 1 year after su rgery h ealin g sh ou ld be com plete

en ou gh to allow rem oval of th e n ails ( Fig 7.3 -8 ).

19 0
 7.3 Pa t h o lo gica l fe m o ra l fra ct u re (32 -D/ 5 .1)

5 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n (co n t)

Fig 7.3 -7a – bAP an d lateral x-rays at 3 AP an d lateral x-rays taken

Fig 7.3 -8 a – b Fig 7.3 -9 a – bFin al resu lt.
m on th s dem on strate good callu s form a- after 1 year dem on strate com plete h eal- AP an d lateral x-rays at th e n al ou t-
tion w ith com plete h ealin g of th e cyst. in g an d rem odelin g. patien t visit 2 years post-operative. Th e
n ails were still in place at th e paren t’s
requ est.

191
 7 Sp e cia l in d ica t io n s

19 2
7.4 Pathological distal fem oral fracture (33-M/ 3.1)

1 Ca s e d e s crip t io n

Wh ile participatin g in a soccer m atch , th is 9-year-old boy ex perien ced th e

im m ed iate on set of in ten se pain in h is righ t k n ee after on ly a sligh t fall.
He was tran sported by am bu lan ce to th e h ospital in a plaster cast splin t. Th e
clin ical exam in ation revealed a pain fu l swollen righ t k n ee.
X-rays sh owed a path ological fractu re at th e d istal m etaph ysis th rou gh an
exten sive cystic lesion ( Fig 7.4 -1 ).

Fig 7.4 -1a – b AP an d lateral x-rays of th e r igh t fem u r dem on strate an essen -
tially u n d isplaced m in im al path ological fractu re th rou gh a cystic lesion in
th e d istal d iaph yseal-m etaph yseal region .

As s e s s m e n t o f th e p a th o lo gy
Th ese x-rays were evalu ated by a team con sistin g of a ped iatric su rgeon ,
pediatric on cologist, an d a ped iatric rad iologist wh o agreed th at th e lesion
appeared to be ben ign . Th ere were n o m align an t ch an ges. Th e lesion was felt
b
to be con sisten t w ith a u n icam eral bon e cyst.

2 In d ica t io n

Th e in d ication s for su rgical treatm en t w ith ESIN: Tre a tm e n t a lte rn a t ive s

Th is was an extrem ely u n stable fractu re. Becau se of th e proxim ity to th e physis, th e recom m en ded
Th e tim e for h ealin g of th e fractu re was pred icted to be treatm en t was to redu ce an d stabilize th e fractu re u tilizin g
ver y lon g. th e ESIN tech n iqu e. An extern al xator was con sidered as an
With ou t su rgical stabilization , th e extrem ity wou ld altern ative, bu t it was felt th at th e ESIN tech n iqu e provided
requ ire a prolon ged im m obilization tim e. m ore advan tages an d a lower rate of com plication s.
Th ere n eeded to be som eth in g in th e treatm en t m eth od
th at wou ld also stim u late resolu tion of th e cyst alon g
w ith redu ction of th e tu m oral m ass.
Th e an ticipated lon g h ealin g tim e an d th e sh ortn ess of
th e d istal fragm en t was con sidered to be a con train d ica-
tion for extern al xation .

19 3
 7 Sp e cia l in d ica t io n s

3 Su rgica l a p p ro a ch

0 .5 –1 cm

1–2 cm

Fig 7.4 -2 Prox im al en tr y poin ts. Fig 7.4 -3 Sk in in cision an d d rillin g of en try poin ts.
In th e su btroch an ter ic region , th e two Th e proxim al sk in in cision starts ju st below th e greater troch an ter an d exten ds
an terior-lateral en tr y poin ts sh ou ld be d istally 3 –4 cm to ju st below th e lesser troch an ter. It n eeds to be su f cien t to allow
separated by 1–2 cm . en ou gh ex posu re of th e prox im al sh aft for th e two separate en tran ce sites (sm all
circles). On ce en gaged, th e aw l is directed 45° to facilitate an tegrade advan cem en t
of th e n ails.

4 Re d u ct io n a n d fixa t io n

Th e exact tech n iqu e of an tegrade n ailin g is described in detail Se co n d n a il

u n der su rgical tech n iqu e in ch apter 5.6 Distal fem oral frac- On ce th is fragm en t h as been su f cien tly stabilized, start w ith
tu re. On ly th e im portan t poin ts of th is tech n iqu e w ill be th e secon d n ail w h ich h as an accen tu ated precon tou r in its
repeated h ere. d istal th ird. On ce th e secon d n ail is advan ced d istally to th e
level of th e cyst, rotate it 180 º so as to preven t th e corkscrew
Th e biopsy th at was perform ed prior to ESIN redu ction an d ph en om en on ( Fig 7.4 -4 b ).
stabilization con rm ed th e in itial d iagn osis of an u n icam eral
bon e cyst. Dis t a l fra gm e n t s t a b iliza tio n
Fin ally, align th e d istal fragm en t correctly in both th e sagittal
Th e lateral su btroch an teric in cision is m ade a little lon ger an d coron al plan es.
th an n orm al to allow en ou gh room to be able to h ave two
lateral en try poin ts. Open th e m edu llar y can al. On ce th e d istal fragm en t h as been properly align ed, both n ails
can th en be h am m ered in to th e distal epiph ysis ( Fig 7.4 -4 c).
Prim a r y s t a b iliza t io n Prior to advan cin g th e n ails to th eir n al position , th ey m u st
First, in sert th e n orm ally precon tou red n ail as u su al. Advan ce be m easu red an d cu t so th at on ly abou t 1 cm rem ain s pro-
it d istally to th e fractu re site situ ated in th e cystic zon e. Be tru d in g from th e lateral cortex of th e prox im al femu r.
carefu l n ot to perforate or exit th rou gh th e th in cortex at th is
level. Use th is rst n ail to stabilize th e d istal fragm en t tem po- In som e cases su ch as th e on e described h ere, th ere m ay be
rarily ( Fig 7.4 -4 a ). en ou gh bon e in th e d istal fragm en t n ot to n eed to pen etrate
th e d istal ph ysis ( Fig 7.4 -4 d ).

19 4
 7.4 Pa t h o lo gica l d is t a l fe m o ra l fra ct u re (3 3 -M/ 3 .1)

4 Re d u ct io n a n d fixa t io n (co n t)

Fig 7.4 -4 a – f
a Perform a closed redu ction an d secu re
prelim in ar y xation w ith th e rst lat-
eral n ail advan ced d istally from th e
lateral su btroch an teric region .
b – c Th e secon d lateral n ail is advan ced d is-
tally to th e cyst as well. Notice th e
dou ble con tou rin g (S-sh ape) of th e
n ail wh ich cau ses th e tip of th is secon d
n ail to be d irected towards th e m ed ial
con dyle.
d Fin al tip placem en t. On ce both n ails
h ave been advan ced to th e correctly
redu ced d istal fragm en t th ey are
driven across th e ph ysis in to th e epiph -
ysis to ach ieve th e n al stability in to
th e m etaph yseal bon e.

a b

18 0 °

c d

19 5
 7 Sp e cia l in d ica t io n s

4 Re d u ct io n a n d fixa t io n (co n t)

Fig 7.4 -4 a – f (co n t)

e – f Fin al im plan tation . AP an d lateral x-rays dem on strate a satisfactor y redu ction
w ith n ot optim al position in g of th e two n ails (th e rst n ail sh ou ld h ave been
m ore precon tou red so th at th e in n er-cortical con tact is better). In th is case,
con trary to th e previou s gu re, su f cien t stability was ach ieved w ith ou t pen -
etratin g th e physis.

5 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

In itit a l m o b iliza tio n At th e secon d ou t-patien t visit at 6 m on th s, X-rays sh ou ld

As in all cases, adequ ate pain m an agem en t is im portan t. dem on strate com plete rem odelin g an d h ealin g of th e cyst
( Fig 7.4 -5 ).
Usu ally th e patien t rem ain s in bed for th e rst 2 days.
On day 3 m obilization u n der th e su per vision of a ph ysioth er- Th e h ealin g an d rem odelin g processes sh ou ld be com plete
apist is begu n w ith a partial weigh t-bearin g gait. en ou gh at 1 year to perm it n ail rem oval ( Fig 7.4 -6 ).
Sin ce th e en try poin ts are proxim al, n eith er th e m obility of
th e k n ee n or th e ex ibility of th e iliotibial tract are restricted. Fin a l re co ve r y
Th is en h an ces th e rapid ity of th e reh abilitation process. At 2 years follow in g th e operation , th ere sh ou ld be fu ll recov-
ery clin ically as m an ifested by n orm al in tern al an d extern al
Ou tp a t ie n t fo llo w -u p rotation of th e h ip an d equ al leg len gth s ( Fig 7.4 -7 ).
Disch arge from th e h ospital u su ally occu rs on day 5, h avin g
ach ieved fu ll h ip an d k n ee m otion . Th e rst ou t-patien t visit
u su ally occu rs at 2 m on th s post-operative. If th e x-rays taken
at th at tim e dem on strate com plete h ealin g of th e fractu re, fu ll
sport activity can be perm itted.

19 6
 7.4 Pa t h o lo gica l d is t a l fe m o ra l fra ct u re (3 3 -M/ 3 .1)

5 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n (co n t)

Fig 7.4 -6 a – b AP and lateral

x-rays, follow in g n ail re -
m oval at 1 year after th e pri-
AP and lateral
Fig 7.4 -5 a – b m ary su rgery dem on strate
x-rays 6 m onth s postopera- essen tial bone arch itectu re
tively sh ow nearly com plete w ith the exception of a rem -
rem odelin g an d h ealin g of n an t of th e distal can al of th e
th e cyst. n ail.

Fig 7.4 -7a – e Com plete clin ical recovery

at 2 years. Th ere is
a fu ll h ip an d k n ee ex ion , th e
scar at th e prox im al th igh is visible
(arrow).
b In tern al an d
c extern al h ip rotation w ith th e h ips
exed; an d
d fu ll in tern al an d
e extern al h ip rotation in exten sion
(arrow).

19 7
 7 Sp e cia l in d ica t io n s

19 8
7.5 Com ple x clavicular fracture s

1 Ca s e d e s crip t io n

Ca s e 1 Ca s e 2
A 13-year-old fem ale fell from h er bicycle strik in g h er righ t A 15-year-old tall fem ale presen ted 1 year after sh e h ad su s-
sh ou lder directly again st th e grou n d. Th ere was im m ed iate tain ed a severely d islocated clavicu lar fractu re. Sh e ex h ibited
on set of pain a n d swellin g at th e area of th e m id clavicle. Th e an extrem ely poor cosm etic appearan ce an d ex perien ced pain
in ju r y x-rays dem on strated m idsh aft fractu re of th e clavicle at th e fractu re site ( Fig 7.5 -2 ).
w ith a rotated in term ed iar y fragm en t. Th e clavicle was sh ort-
en ed by 2.5 cm ( Fig 7.5 -1).

Sh e was in itially treated con servatively w ith a rin g or qu oit

ban dage.
Sh e presen ted 4 days later to th e ou t-patien t clin ic w ith severe
pain . Th e sk in at th e fractu re site sh owed sign s of im pen d in g
sk in pen etration . Th ere was an in crease in th e sh orten in g an d
d isplacem en t of th e clavicu lar fragm en ts on th e x-rays.

Fig 7.5 -1a – b Fig 7.5 -2 a – b Un sigh tly prom in en ce. AP an d lateral view s of
a X-rays taken at th e rst clin ic visit. Th e m idportion frag- th e righ t sh ou lder sh ow in g sh orten in g of th e sh ou lder alon g
m en ts h ave rotated an d sh orten ed. w ith a pain fu l prom in en ce from th e m alu n ion of th e m idsh aft
b Sh orten in g an d rotation . Sch em atic draw in g of th e sh ort- of th e clavicle.
en ed clavicu lar fractu re w ith a rotated in term ediar y frag-
m en t.

19 9
 7 Sp e cia l in d ica t io n s

2 In d ica t io n

Th e vast m ajor ity of clavicu lar fractu res can be su ccessfu lly Pe rm a n e n t d e fo rm it y
treated by con ser vative m an agem en t. However, in som e cases Th is sh orten in g of th e clavicle fails to recover in th e older ch ild
of ch ildren treated con ser vatively, th ere h ave been reports of resu ltin g in an u n acceptable asym m etry of th e sh ou lder.
n onu n ion an d sh orten in g of th e sh ou lder w ith in stan ces of
poor cosm etic an d fu n ction al resu lts. Du e to th eir vast experien ce w ith th ese fractu res, th e AO
pediatric su rgeon s h ave deter m in ed th e follow in g in d ication s
Su rge r y ra re ly in d ica te d for th e su rgical m an agem en t of claviclu lar fractu res:
Clearly, su rgical in terven tion is rarely in d icated. In th ose cases Severe d isplacem en t w ith poten tial skin perforation
wh ere su rger y is n ecessar y, th e in d ication s are n ot strictly Sh orten in g an d/or in stability of th e sh ou lder
de n ed. Th ese rare in d ication s, alon g w ith th e tech n iqu es for Possible prolon ged m orbid ity becau se of im pin gem en t on
th e operative stabilization of clavicu lar fractu res in th e ped i- th e soft tissu e
atric patien t, w ill be exam in ed in th is section . Open fractu res
Neu rovascu lar com prom ise
Prim a r y in d ica t io n Risk to m ed iastin al stru ctu res
Th e prim ar y in d ication s occu r in m id-sh aft clavicu lar frac- Cosm esis
tu res w ith severe sh orten in g in th e older ch ild. Wh ile m ost
of th ese are sim ple fractu res, th ere are som e w ith an in ter- Two of th e su rgical in dication s are exam in ed in th e case pre-
m ediate fragm en t wh ich is rotated 90° produ cin g severe sh ort- sen tation s.
en in g. Th is rotated fragm en t can also ten t th e sk in pred is-
posin g it to perforation .

Pre o p e ra t ive p la n n in g 3 Su rgica l a p p ro a ch

Eq u ip m e n t Two prim ar y tech n iqu es are available for th e stabilization of

Sin ce th e cla vicle is n o t a co m p le te tu b u la r b o n e , th e so -ca lle d fractu res of th e clavicle w ith ESIN. Th ese two tech n iqu es are
m e d u lla ry ca vit y is ve ry n a rro w. Th is re q u ire s th e u se o f sm a ll perform ed totally percu tan eou sly.
n a ils su ch a s th o se w ith 2 .0 m m o r 2 .5 m m d ia m e te rs .
(Size o f s ys te m , in s tru m e n ts, a n d im p la n ts ca n va ry a cco rd in g to a n a to m y.) A percu tan eou s retrograde tech n iqu e in wh ich th e n ails
are passed from lateral to m edial.
Pa t ie n t p re p a ra t io n A percu tan eou s an tegrade tech n iqu e in wh ich th e n ails
a n d p o s it io n in g are passed from m edial to lateral.
Fig 7.5 -3 It is im p o rta n t to
p la ce th e ch ild d o w n o n th e
fre e e n d o f th e o p e ra tin g ta b le .
Th e im a ge in te n si e r m u s t b e
situ a te d so th a t it ca n b e
ro ta te d 9 0 º a n d a ll p o rtio n s o f
th e cla vicle ca n b e
e a sily visu a lize d .

20 0
 7.5 Co m p le x cla vicu la r fra ct u re s

4 Re d u ct io n a n d fixa t io n

18 0 °

a b

Fig 7.5 -4 a – d Lateral approach .

a Th e n ail tip is in serted percu tan eou sly in to th e dorso – b Th e n ail is advan ced retrograde u n til th e tip reach es th e
lateral cortex of th e d istal fragm en t. fractu re su rface. At th is poin t th e n ail m u st be tu rn ed 180 º
so th at th e tip can en gage th e in term ed iar y fragm en t. On ce
th is fragm en t is align ed, th e n ail is th en advan ced retro-
grade th rou gh th is fragm en t an d an ch ored in th e proxim al
fragm en t.

c d

c Th e n ail is advan ced th rou gh th e in term ediar y fragm en t d De n itive position in g. Th e n ail is rotated u n til a satisfac-
in to th e prox im al fragm en t. In th e case presen ted h ere, th e tor y align m en t of th e clavicle h as been ach ieved.
fragm en t was rotated th rou gh an open in cision .

2 01
 7 Sp e cia l in d ica t io n s

4 Re d u ct io n a n d fixa t io n (co n t)

Th e lateral approach requ ires a sh ort in cision in th e sk in

prom in en ce over th e rotated in term ed iar y fragm en t
( Fig 7.5 -4 a ). On ce th e fractu re is ex posed, th e blu n t en d of th e
n ail is in serted th rou gh th e m edu llar y can al in to th e distal
fragm en t an d th en advan ced an tegrade u n til it pen etrates th e
dorsal-lateral cortex an d sk in over th e lateral clavicle. Th e n ail
is th en extracted u n til th e n ail tip is even w ith th e edge of th e
fractu re su rface of th e distal fragm en t. Th e in term ed iar y frag-
m en t is th en rotated th rou gh th e sm all origin al in cision so
th at its fractu re su rface is in lin e w ith th at of th e distal frag-
m en t ( Fig 7.5 -4 b ). Th e tip of th e n ail is th en in serted in to th e
proxim al fragm en t to be advan ced retrograde su f cien tly to
stabilize all th ree fragm en ts ( Fig 7.5 -4 c).

Becau se of th e im pen din g sk in perforation , an open redu ction

is th e procedu re of ch oice.
Th is in volves u sin g th e th ird su rgical approach ( Fig 7.5 -6 ).

Make a sh ort skin in cision over th e fragm en t.

Th e fractu re su rface of th e m ain d istal fragm en t is Fig 7.5 -5 Medial approach . Th e n ail tip is in serted th rou gh a
ex posed. sm all sk in in cision m ed ially to perforate th e cortex of th e
After in sertion of th e blu n t en d in to th e m edu llar y m ed ial clavicle. Th e redu ction an d advan ce of th e n ail in an
can al, a 2.5 m m n ail is advan ced an tegrade in to th e d istal an tegrade d irection is sim ilar to th at perform ed in th e lateral
fragm en t. approach .
Th e tip of th e n ail perforates th e d istal clavicle proxim al–
dorsally adjacen t to th e d istal ph ysis. Sin ce th e in dication s in ch ildren m ain ly in volve fractu res
Th e sk in is perforated an d th e n ail is extracted. w ith severe sh orten in g an d m arked rotation of an in term ed i-
Th e fragm en ts are align ed an d th e n ail is advan ced ary fragm en t, a th ird approach is su ggested ( Fig 7.5 -6 ).
retrograde an d an ch ored in th e prox im al fragm en t.
Th e n ail is given a n al rotation to correct align m en t of
th e clavicle.
On ce im plan ted, th e n ail is cu t to its correct len gth an d
an ch ored de n itively.

202
 7.5 Co m p le x cla vicu la r fra ct u re s

4 Re d u ct io n a n d fixa t io n (co n t)

a b

Fig 7.5 -6 a – b Approach from th e fractu re site.

a Follow in g carefu l su rgical preparation of th e sk in , th e b Th e in term ed iary fragm en t is th en rotated th rou gh th e
fractu re site is open ed th rou gh a sm all in cision over th e sk in in cision to align it w ith th e two oth er fragm en ts. On ce
fractu re. Th e blu n t en d of th e n ail is th en passed an tegrade th e fragm en ts are correctly align ed, th e n ail tip is advan ced
th rou gh th e d istal fragm en t to em erge th rou gh th e cortex retrograde an d an ch ored in th e prox im al fragm en t.
an d sk in dorso-laterally in th e sh ou lder. Th e n ail is
extracted u n til th e tip is at th e level of th e fractu re site.

Fig 7.5 -7 In itial x-ray. At th e in itial pre- Fig 7.5 -8 Developm en t of sh orten in g. Fig 7.5 -9 Postoperative x-ray. Satisfac-
sen tation , a gu re-of-eigh t h arn ess was Th e x-ray taken 4 days later at th e rst tor y align m en t was ach ieved w ith th e
applied. ou t-patien t clin ic dem on strated sign i - x-ray dem on stratin g exactly th e desired
can tly in creased sh orten in g an d rota- position of im plan tation .
tion of th e fragm en ts.

203
 7 Sp e cia l in d ica t io n s

5 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

With adequ ate pain con trol, th ese fractu res can u su ally be m an aged as
an ou tpatien t procedu re. For m ore com plex fractu res, wh ere an exten -
sive procedu re was perform ed, an overn igh t stay m ay be n ecessary for
pain con trol.

Fig 7.5 -10 Fin al recovery. X-ray taken 8 weeks postoperative dem on -
strates excellen t h ealin g an d rem odelin g. Be -cau se it was n ot n ecessary
to take x-rays follow in g n ail rem oval, n al x-rays are n ot available.

6 Pit fa lls – 7 Pe a rls +

Ap p ro a ch Ap p ro a ch
If th e en tr y poin t for th e an tegrade tech n iqu e is Avoid creatin g lon g u n sigh tly scars as th is is particu larly
too m ed ial, th ere is a dan ger of dam age to th e stern o- im portan t in th is an atom ical region .
clavicu lar join t.
Im properly placed in cision s can produ ce u n favou rable
It m ay be d if cu lt to open or en ter th e m edu llary can al cosm etic resu lts.
becau se of th e th ick cortex.

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
Th e m edu llary can al is too n arrow to allow passage of To preven t prox im al m igration of th e n ail in to th e ch est,
th e n ails. a sm all ben d is placed in th e cu t en d of th e n ail as it
A closed redu ction can n ot be obtain ed. lies ju st ou tside th e d istal cortex. Th is ben d is th en rotated
to lie u sh again st th e dorsal cortex.

Re h a b ilit a tio n Re h a b ilit a tio n

Im m ed iate m obility of th e sh ou lder is possible. It is
ver y im portan t for a ch ild of th is age to retu rn to n orm al
activities as soon as possible.

If th ere is good xation an d realign m en t, recover y is

n orm ally u n even tfu l.

204
7.6 Subcapital fracture of m e tacarpal V

1 Ca s e d e s crip t io n

A 12-year-old boy in ju red h is left h an d w h ile participatin g in

a soccer gam e at sch ool.
Th e in itial x-rays dem on strated a severely d isplaced Salter-
Harris II fractu re of th e n eck of m etacar pal V ( Fig 7.6 -1).

Becau se of th e m arked d isplacem en t an d th e age of th e patien t,

th ere was u n iversal agreem en t th at th is fractu re requ ired a
m an ipu lative redu ction . Sin ce th ese are u n stable fractu res,
th is posed th e qu estion as to wh at wou ld be th e ideal m eth od
of stabilization .
Th ree possibilities for post-redu ction m an agem en t were con -
sidered:
Closed redu ction an d plaster cast.
Closed redu ction w ith K-w ire xation su pplem en ted w ith
a plaster cast.
a b b
Closed redu ction an d ESIN stabilization elim in atin g th e
n eed for any oth er im m obilization .
Fig 7.6 -1a – b
a In ju r y x-ray of th e h an d dem on stratin g a sign i can tly
d isplaced fractu re th rou gh th e n eck of m etacar pal V.
b Displacem en t pattern . Graph ic represen tation of th e dis-
placem en t of th e h ead of m etacar pal V.

2 In d ica t io n

As a ru le, fractu res of th e sm all lon g bon es (m etacar pal bon es, cou pled w ith ESIN stabilization . Th is u su ally elim in ates the
ph alan ges of th e n gers, m etatarsal bon es) do n ot presen t an y n eed for postoperative im m obilization w ith a plaster cast.
com plication s in th e ped iatric patien t. Th ese fractu res u su ally Th e prim ar y in dication s for ESIN stabilization in pediatric
h eal rapid ly w ith ou t problem s in th ose patien ts u p to th e age patien ts are seen in fractu res occu rrin g in :
of twelve. However, after th at age, th e rem odelin g capacity Sh aft an d su bcapital areas of m etacar pals II an d V.
h as ceased an d th e treatm en t n eeds to be m ore aggressive to Th e th u m b.
ach ieve a satisfactory ou tcom e. Th erefore, fractu res even in Th e proxim al ph alan ges.
th is area requ ire an an atom ical redu ction an d in m an y cases Metatarsals I an d V.
su rgical stabilization . In rare occasion s in th e oth er sm all lon g bon es.

The AO pediatric su rgeon s h ave fou n d th at the best m ethod of In adu lts, th is m eth od h as becom e in creasin gly establish ed as
m an agem en t in th e presen t era is to perform a closed redu ction th e m eth od of ch oice.

205
 7 Sp e cia l in d ica t io n s

2 In d ica t io n (co n t) Pre o p e ra t ive p la n n in g

Pa t ie n t p re p a ra t io n a n d p o s it io n in g

Fig 7.6 –2 Th ese fractu re pattern s in th e bon es of th e h an d Fig 7.6 -3 Im a ge se t-u p . Th e co rre ct p o sitio n in g o f th e ch ild w ith
can be easily stabilized w ith th e ESIN tech n iqu e. th e fra ctu re d h a n d re stin g d ire ctly o n th e re ce p to r su rfa ce o f th e
im a ge in te n si e r. Ad va n ta ge : b e t te r im a ge q u a lit y, le ss ra d ia tio n .

3 Su rgica l a p p ro a ch

Norm ally, th e n ails are in serted an d passed in an an tegrade Two alteration s in th e tech n iqu e can facilitate th e im plan ta-
d irection . Th ese fractu res can also be stabilized w ith a retro- tion of th e n ails w ith th ese fractu res:
grade tech n iqu e. Th e m ajor problem occu rs becau se of th e First, it is recom m en ded th at th e operation is perform ed
poor soft tissu e cover over th e en d of th e n ail. d irectly on th e receiver of th e in ten si er ( Fig 7.6 -3 ). Th is
im proves th e qu ality of th e im age for th ese sm all bon es.
Th e fractu re pattern determ in es wh eth er it w ill be best to sta- Secon d, if available, u se th e m agn i cation program .
bilize w ith on e or two n ails. In m ost cases, on e n ail is u su ally
su f cien t.

Th is ESIN tech n iqu e of stabilization for m etacar pal su bcapital

fractu res is very sim ilar to th at for stabilizin g radial h ead an d
n eck fractu res.

20 6
 7.6 Su b ca p ita l fra ctu re o f m e ta ca rp a l V

4 Re d u ct io n a n d fixa t io n

Place th e h an d d irectly on th e su rface of th e receiver of th e u llary can al in th e u su al m an n er. Th e n ail is advan ced d istally
im age in ten si er. to th e fractu re site ( Fig 7.6 -5 ).

Entry po int Fra cture s ta biliza tio n

The entry poin t for the an tegrade tech n ique is iden ti ed At th is poin t, rotate th e tip to d irect it in to th e d istal fragm en t
on th e dorsu m of th e proxim al-u ln ar aspect of m etacarpal V, ( Fig 7.6 -6 ). If th e fragm en t ts well on th e n ail, advan ce it
abou t 5 –6 m m distally to th e carpal-m etacarpal join t ( Fig 7.6 -4 ). an oth er 2–3 m m an d rotate th e tip 180° to secu re th e redu c-
Con rm th e location of th e en try poin t w ith th e in ten si er. tion . If n ecessary, place a n ger d irectly over th e fragm en t to
Perforate th e cortex w ith a sm all aw l or a 2.5 m m K-w ire. Cu t press it in to position . At th is poin t, th e fragm en t sh ou ld be
a 2.0 m m n ail 12 –15 cm prox im al from th e tip. Precon tou r th e secu red in its n al position ( Fig 7.6 -7 ). Th e n ail is th en cu t so
d istal th ird of th e n ail. In sert th e sh orten ed n ail in to th e m ed- th e en d lies w ith su f cien t sk in an d su bcu tan eou s tissu e cov-
erage to avoid later pen etration .

e
a b c d

18 0 °

Fig 7.6 -4 a – e
a En tran ce poin t. Th e precon tou red n ail is in serted in to th e d Redu ction m an eu ver. On ce seated in th e h ead, th e tip of
dorso-u ln ar su rface of th e base of m e tacar pal V. th e n ail is ro tated to effect a n al redu ction .
b An tegrade in sertion . Th e n ail is advan ced d istally to th e e Fin al redu ction . X-ray of th e n al redu ction an d position
fractu re site. of th e n ail.
c In sertion in to th e h ead. Th e n ail is th en m an ipu lated so
th at th e tip w ill en ter in to th e cen ter of th e n eck-h ead frag-
m en t.

207
 7 Sp e cia l in d ica t io n s

5 Re h a b ilit a t io n

As w ith all fractu res, adequ ate pain m a -n agem en t is im por-

tan t.
It is possible to perform th is procedu re in an ou tpatien t day
su rgery settin g. Th e degree of pain determ in es th e len gth of
h ospital stay.
Addition al im m obilization an d ph ysioth erapy are n ot u su ally
n ecessar y.
Th e rst ou tpatien t visit an d x-rays are perform ed at 4 weeks.
Depen d in g on th e m obility of th e h an d after th is exam in a-
tion , participation in sch ool sports activities can begin .
Th e im plan t can be rem oved after 2–3 m on th s, in accordan ce
w ith th e desires an d con ven ien ce of th e paren ts.
Sin ce n o add ition al x-rays are n ecessary, x-rays w ith ou t n ails
are n ot available for th is case.
Fig 7.6 -5 Fin al h ealin g.
X-ray dem on stratin g th e location of th e n ail w ith callu s at th e
fractu re site.

6 Pit fa lls – 7 Pe a rls +

Ap p ro a ch Ap p ro a ch
Becau se of th e th in cortices of th e Becau se th ere is n o exposed m etal, th e in fection rate is
bon es an d th e n arrow join t spaces, lower th an for th e u se of cross pin s.
th ere is a h igh risk of perforation
of th e join t or th e cortex ( Fig 7.6 -6 ).

Fig 7.6 -6 Join t pen etration . Th e

n ail is advan ced too distally cau sin g
th e tip to perforate th e join t.

20 8
 7.6 Su b ca p ita l fra ctu re o f m e ta ca rp a l V

6 Pit fa lls – (co n t) 7 Pe a rls + (co n t)

Re d u ct io n a n d xa t io n Re d u ct io n a n d xa t io n
In ter position of a ten don or
oth er adjacen t soft tissu e m ay
preven t adequ ate redu ction .
An in appropriate evalu ation of th e
level of th e fractu re or d irection
of n ailin g can also m ake it eith er
d if cu lt or im possible to ach ieve
an adequ ate redu ction .

a b c
Fig 7.6 -7 Cortical pen etration .
Th e con tra-lateral cortex is perfora-
ted w ith th e awl cau sin g th e n ail to
advan ce ou tside th e bon e.

d e f

Fig 7.6 -8 a – fTwo-n ail stabilization . A Salter-Harris I frac-

tu re is stabilized by two n ails.

Re h a b ilit a tio n Re h a b ilit a tio n

Even w ith th e ability to in itiate early m otion , som e of th e Sin ce a postoperative splin t or plaster cast is n ot requ ired,
join ts m ay rem ain stiff. th e resu lt is u su ally a free ran ge of join t m otion . Th is
allow s a rapid retu rn to n orm ality w ith regard to partici-
pation in sch ool activities.

209
 7 Sp e cia l in d ica t io n s

210
7.7 Radial ne ck m alunion

1 Ca s e d e s crip t io n

15-year-old fem ale w ith a 14 m on th -old sk iin g in ju ry presen ted w ith

elbow d islocation an d n eglected rad ial n eck fractu re.

Ph ysioth erapy was started 6 weeks after in ju r y. Du rin g th e follow in g

m on th s sh e sh owed persisten ce of lim ited elbow m otion . Exten sion /
exion 0°–15°–120°; pron ation /su pin ation 20°–0°–40°.

Th e x-rays at th is tim e sh owed an an gu lation of th e rad ial h ead ( Fig 7.7-1).

It was recom m en ded to wait, as th is type of m alu n ion u su ally corrects
itself in ch ild h ood.

Restriction of m ovem en t con tin u ed for a fu rth er 12 m on th s. Th erefore a

corrective osteotom y was recom m en ded.
Fig 7.7-1a – bX-rays 14 m on th s after in ju ry; m ax i-
m al pron ation an d su pin ation as well as m axim al
exten sion .

2 In d ica t io n

It was obviou s th at a correction was n ecessar y to treat th e severe h an d i-

cap. Adequ ate correction m u st be on th e level of th e old fractu re, m ean -
in g in traarticu lar.

Th e follow in g option s for treatm en t were d iscu ssed:

A corrective osteotom y an d plate xation wh ich is a com plex su rger y
a
w ith a h igh risk of avascu lar n ecrosis of th e rad ial h ead. On th e oth er
h an d, a plate xation also carries th e risk of fu n ction al problem s
becau se of th e proxim al approach .
M in im ally in vasive osteotom y an d K-w ire xation w ith a plaster cast;
n o fu n ction al treatm en t.
Treatm en t based on th e con cepts of redu ction an d stabilization of
rad ial n eck fractu res. With th is tech n iqu e it sh ou ld also be possible to
stabilize a n ear-h ead correction osteotom y. Th is was th e m eth od of
b ch oice for th is case ( Fig 7.7-2 ).

Fig 7.7-2 a – b Plan n in g of th e su bcapital osteotom y.

211
 7 Sp e cia l in d ica t io n s

3 Su rgica l a p p ro a ch

Start w ith th e preparation of th e radial n eck from

a lateral approach . Perform a dorsolateral open in g
of th e radio-hu m eral join t. Carefu lly split th e
an nu lar ligam en t w ith a su rgical k n ife. Th e radial
n eck can n ow be seen w ith th e deform ation an d
partial d islocation of th e h ead.

Fig 7.7-3 a – b Radial approach w ith a 4 –5 cm lon g

in cision . Th e capsu le is open ed ex posin g th e
deform ed rad ial n eck w ith su blu xation .

4 Re d u ct io n a n d fixa t io n

Prepare for distal access at th e rad iu s. Th is is sim i-

lar to th e access u sed for forearm fractu res. In sert
th e rst 2.0 m m n ail. On ly 2 m m n ails are u sed in
th is case ( Fig 7.7-4 ).

Fig 7.7-4 a – b Preparation an d in sertion of th e two

n ails at th e distal radiu s. Th e ou tside n ail in dicates
th e d irection of th e n ail tip.

Perform a partial open wedge su bcapital n eck osteo-

tom y w ith a ch isel or n e saw blade. Good protec-
tion of th e soft tissu e is m an dator y. Circu lation
sh ou ld n ot be at risk if th e work is don e carefu lly
( Fig 7.7-5 )

a b Fig 7.7-5 a – b Sch em atic draw in g of th e open wedge

osteotom y.

212
 7.7 Ra d ia l n e ck m a lu n io n

4 Re d u ct io n a n d fixa t io n (co n t)

Open th e osteotom y w ith th e ch isel,

en su rin g th at th e opposite cortex does
n ot break. Now advan ce th e rst n ail u p
to th e rad ial h ead w ith th e tip to th e
osteotom y side ( Fig 7.7-6 ). Next, advan ce
th e secon d n ail u p to th e osteotom y; th e
a
b tip is tu rn ed 180° in relation to th e rst
Fig 7.7-6 a – b In sertion of th e rst n ail from th e d istal rad ial side. on e ( Fig 7.7-7, Fig 7.7-8 ).

18 0 ° Cu t th e en ds of th e n ails an d en su re
de n itive position in g u sin g th e im pac-
tor ( Fig 7.7-9 ). A sin gle perforation of th e
grow th plate does n ot m atter.

In th is case the defect was lled w ith

sm all bone-block from the u ln a. In retro-
spect th is m ay n ot h ave been n ecessary.
a
b
Fig 7.7-7a – b In sertion of th e secon d n ail. Th e postoperative x-ray sh ow s a good
align m en t of th e rad ial h ead. In tra-
operatively th e pron ation an d su pin a-
tion was 60°–0°–60° ( Fig 7.7-10 ).

a b

Fig 7.7-8 a – b Movem en t u p to th e epiph ysis.

a b
Fig 7.7-10 a – bPostoperative x-rays w ith
Fig 7.7-9 a – b Fin al xation in th e fragm en t by both n ails. bon e graft in place.

213
 7 Sp e cia l in d ica t io n s

5 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Becau se two n ails h ave been u sed th e fragm en t h as been Sch ool sport was allowed after 8 weeks. Un problem atic h eal-
secu rely stabilized. in g was obser ved.
Th e patien t stayed in h ospital for 4 days. Free ran ge of m otion
was allowed. Nail rem oval after 8 m on th s. No sign of avascu lar n ecrosis was
At th e rst ou tpatien t con trol after 5 weeks, th e patien t h ad seen at th is poin t ( Fig 7.7-11 , Fig 7.7.-12 ). Pron ation /su pi-
n o pain , bu t still lim ited m otion . n ation was 70°–0°–70° com parable to in traoperative ran ge of
m otion .
Preoperative: Pron ation /su pin ation 20°–0°–4 0°
In traoperative: Pron ation /su pin ation 75°–0°–65°
First con trol: Pron ation /su pin ation 60°–0°–55°

Fig 7.7-12 a – b Clin ical situ ation after n ail rem oval.

Fig 7.7-11a – bX-rays after n ail rem oval (8 m on th s postopera-

tive) sh ow good align m en t an d fu ll exion .

214
7.8 Radial and ulnar m alunion

1 Ca s e d e s crip t io n

11-year-old girl fell from a tree on to h is righ t arm .

Pain an d deform ation of th e forearm .

Th e x-ray sh owed a fractu re of th e u ln a an d a bow in g

of th e rad iu s ( Fig 7.8 -1). Th e elbow join t, respectively
th e rad ial h ead was u n obtru sive. Th e bow in g of th e
rad iu s cou ld be clearly seen . Th e xation was carried
ou t in th e plaster cast for 4 weeks.

Th is resu lted in a con siderable cu rvatu re w ith restricted

pron ation an d su pin ation (10°–0°– 40°). Ten m on th s
after th e acciden t th e qu estion of correction arose
( Fig 7.8 -2 ).

Con sideration s:
a b a b Th e rem odelin g capacity of forearm sh aft fractu res
is ver y bad.
Fig 7.8 -1a – b In ju r y x-ray. Fig 7.8 -2 a – bSitu ation 10 After 10 m on th s th e rem odelin g is com plete; th e
Un displaced fractu re of th e m on th s after in ju ry. ex istin g m alu n ion w ill n ot im prove fu rth er.
u ln a an d severe bow in g Th e ch ild is over 10 years old.
of th e rad iu s. Fu n ction al m alu n ion s of th e forearm in patien ts
after m ore th an 1–2 years can be corrected an a-
tom ically bu t n ot fu n ction ally.
In d ication is th erefore to correct su ch a fu n ction -
ally bad in itial position as qu ickly as possible.

2 In d ica t io n

How can th is correction been don e? Trad ition ally, a plate Th e treatm en t option ch osen is a m in im ally in vasive proce-
wou ld be u sed. However, th is m ean s a su bstan tial operation du re w ith th e ESIN m eth od.
an d a dan ger of refractu re after plate rem oval. Plate osteosyn - 1–2 cm lon g incision s at the level of the plan n ed osteotomy.
th esis is also always associated w ith large scars. In sertion of two n ails u sin g a well k n ow n tech n iqu e.
Fu n ction al postoperative m an agem en t.

215
 7 Sp e cia l in d ica t io n s

2 In d ica t io n (co n t) 3 Su rgica l a p p ro a ch

It was plan n ed to perform two osteoto- Stan dard approach to th e distal radiu s (see ch apter 4.7
m ies at th e level of th e severest an gu la- Displaced d istal rad ial an d u ln ar d iaph yseal-m etaph yseal
tion over separate sh ort 1–2 cm in ci- fractu res).
sion s.
The two n ails are in serted from radial dis-
tal and u ln ar proxim al as norm al.
Becau se th e u ln a is n orm ally straigh t, it
was ver y d if cu lt to m ake th is correc-
tion u sin g a n ail.
Th erefore, two d ifferen t m in im ally
in vasive m eth ods were com bin ed: ESIN
an d a sm all extern al xator.

Fig 7.8 -3 Plan n in g of th e osteotom y.

4 Re d u ct io n a n d fixa t io n

a b c d

Fig 7.8 -4 a – d Osteotom y of th e rad iu s bon e. Make an in cision of th e periosteu m an d su bperios-

a Open th e m edu llar y can al w ith th e aw l. teal preparation , an d in sert two sm all Hoh m an n retrac-
b In sert th e n ail u p to th e plan n ed osteotom y. tors. Perform a ch isel osteotom y (th is h eals better, an d
c Make a sh ort sk in in cision over th e plan n ed osteotom y, in volves n o h eat).
followed by blu n t d issection of th e m u scles dow n to th e d Advan ce th e n ail 2 –3 cm over th e osteotom y.

216
 7.8 Ra d ia l a n d u ln a r m a lu n io n

4 Re d u ct io n a n d fixa t io n (co n t)

Osteotom y of th e u ln a. Th e rad ial n ail can be advan ced to prox im al n ow. Th e n ail
m u st be rotated u n til th e rad iu s straigh ten s itself correctly.
Use th e sam e steps as for th e radiu s (th e in sertion poin t is Th e pron ation an d su pin ation m u st be free.
proxim al–rad ial).
In th is case it becam e clear th at th e th in n ail wh ich h ad been
Make a sk in in cision over th e plan n ed osteotom y, followed u sed cou ld n ot correct th e deform ity su f cien tly. Th erefore
by a blu n t d issection of th e m u scles. Make an in cision of th e th e su rgeon ch an ged to a sm all extern al xator to pu ll ou t th e
periosteu m an d pu t th e sm all Hoh m an n retractors arou n d fragm en t.
th e u ln a.
Make fou r sm all in cision s for th e pin s (self-drillin g, self-
Perform a ch isel osteotom y. tappin g 2.5 m m ) followed by a blu n t d issection dow n u p to th e
bon e.
Now straigh ten th e u ln a rst, followed by xation of th e pin s
on a 6 m m con n ectin g rod. Usin g a drill sleeve in sert a ll fou r selldrill Sch an z screw s
per pen d icu lar to th e sh aft.

a b
a b c

Fig 7.8 -5 Osteotom y Fig 7.8 -6 a – c Sw itch to th e extern al xator an d n al placem en t Fig 7.8 -7a – b Postoperative
of th e u ln a. of th e rad ial n ail. resu lt.

217
 7 Sp e cia l in d ica t io n s

5 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

For th e rst 5 days th e patien t wore a plaster splin t. Th is was Sch ool sport an d oth er sports activities were allowed after
don e on th e requ est of th e paren ts in order to cope w ith pain 6 weeks. Nail rem oval after 6 m on th s as a on e-day su rger y.
an d an xiety. Free m obility from th e begin n in g wou ld h ave
been preferable. After th is time fu ll ran ge of motion was ach ieved ( Fig 7.8 -8 c– d ).
No fu rth er problem s were reported.
Th e extern al xator was rem oved after 5 weeks du rin g ou t-
patien t con trol.

Fig 7.8 -8 a – d
a – b Clin ical situ ation preoperative;
c– d 3 years postoperative.

6 Pit fa lls – 7 Pe a rls +

Ap p ro a ch Ap p ro a ch
Ch an gin g to an extern al xator for th e u ln a involves th ree Osteotom y involves on ly a sm all in cision . In stead of th e on e
addition a l sm all sk in in cision s. or two lon g in cision s n ecessary for a plate osteosyn th esis.

Re d u ctio n a n d xa t io n Re d u ct io n a n d xa t io n
Th e n ail was n ot stron g en ou gh to redu ce th e u ln a. Stabilization of th e osteotom y w ith two n ails wou ld h ave
been sim pler, an d in volved less patien t stress.

Re h a b ilit a t io n Re h a b ilit a tio n

No addition al plaster splin t, free m obilization from th e
begin n in g.

218
7.9 Tibial correction oste otom y
(unknown unilateral bone m alform ation)
1 Ca s e d e s crip t io n

2 1/ 2-year-old boy, born w ith a leg len gth d iscrepan cy of 5 cm on th e

righ t leg. Th is spread ou t even ly to fty per cen t on th e th igh an d fty
percen t on th e lower leg. Both bon es were ben t, bu t it was m ore visible
on th e lower leg becau se of less soft tissu e.

Exten sive exam in ation s revealed n o sign s of n eu ro brom atosis, m elorh e-

ostosis, rach itis, or oth er d iseases. Moreover, th e ch ild h ad a form of
dysm or ph ic syn drom e.

Th e in itial opin ion was to wait u n til th e ch ild cou ld ru n . First steps were
taken at 14 m on th s. Th ere was n o spon tan eou s im provem en t or deterio-
ration of th e situ ation .

At age two, walkin g deteriorated resu ltin g from th e m alposition in g of

th e foot.

At th is poin t a possible correction was discu ssed.

a b Experien ce sh ow s th at su ch u n k n ow n bon e diseases h ave th eir ow n

law s. Th ese often con tribu te to h ealin g problem s an d n onu n ion s after a
Fig 7.9 -1a – b X-rays before operation sh ow in g th e su rgical in ter ven tion .
deform ity.

2 In d ica t io n

In respect to th ese d if cu lties, th e follow in g proce-

du re was d iscu ssed w ith th e paren ts:
Carr yin g ou t two osteotom ies on two levels.
Stabilization by ESIN, perh aps w ith a sm all
extern al xator for a sh ort tim e in add ition .
Th e n ail sh ou ld gu aran tee in n er stability in th e
case of delayed h ealin g.

219
 7 Sp e cia l in d ica t io n s

3 Su rgica l a p p ro a ch 4 Re d u ct io n a n d fixa t io n

Patien t in su pin e position on a radiolu cen t operatin g table. In sert th e rst preben t n ail dow n to th e rst osteotom y level.
Com plete th e ch isel osteotom y.
Localization of th e osteotom y level w ith th e im age in ten si er
in accordan ce w ith preoperative plan n in g. Preparation of th e
area over th e bon e w ith two sm all separate in cision s.

Split th e periosteu m an d pu t in two Hoh m an n retractors.

Make preparation s for both n ails an d th e two en tr y poin ts. If
on ly on e n ail can be u sed, a sm all extern al xator w ill be
applied (ration ale: a ver y n arrow m edu llary cavity is visible
on th e x-ray).

Before startin g w ith th e rst osteotom y th e in sertion of th e

rst n ail dow n to osteotom y level is recom m en ded. Make a
proxim al, m ed ial sk in in cision . Perform th e bon e w ith th e
awl.

a b a b

Plan n in g of th e osteotom y levels an d approach es

Fig 7.9 -2 a – b Fig 7.9 -3 a – bPreparation of th e rst osteotom y in AP an d lat-
to th e osteotom y sites an d th e en tr y poin ts of th e n ails. eral view. Th e rst n ail (in th is case th e on ly n ail) is advan ced
dow n to th is level.

220
 7.9 Tib ia l co rre ct io n o s t e o t o m y (u n k n o w n u n ila t e ra l b o n e m a lfo rm a t io n )

4 Re d u ct io n a n d fixa t io n (co n t)

Advan ce th e n ail th rou gh th e osteotom y. Prepare th e secon d In th is case, th e in tram edu llar y can al was too n arrow for th e
osteotom y in th e sam e way as th e rst on e. Com plete th e placem en t of two n ails. In th is situ ation th e add ition al u se of
ch isel osteotom y on th e secon d level. Advan ce th e n ail dow n a sm all extern al xator for rotation al stability is recom -
to th e d istal fragm en t. Rotate th e n ail in su ch a way th at th e m en ded.
ben d corrects th e m alalign m en t. Trim th e n ails.

a b a b

Fig 7.9 -4 a – b Th e n ail is pu sh ed forward in to th e distal frag- Fig 7.9 -5 a – b Preparation of th e secon d osteotom y in AP an d
m en t. lateral view.

2 21
 7 Sp e cia l in d ica t io n s

4 Re d u ct io n a n d fixa t io n (co n t)

a b a b

Fig 7.9 -6 a – b Th e n ail is advan ced over th e secon d osteotom y Fig 7.9 -7a – bApplication of a sm all extern al xator for
an d xes th e d istal fragm en t. By tu rn in g th e n ail, a good rotation al stability. Th is xation is u sed for 3 –4 weeks on ly.
align m en t of th e fragm en ts is ach ieved. It can be rem oved w h en som e callu s form ation is seen .

Fig 7.9 -9 a – b
Fig 7.9 -8 a – b X-rays after
X-rays postop- rem oval of th e
erative corre- extern al xator
spon din g to 8 weeks later.
preoperative Delayed h ealin g
a b a b
plan n in g. can be seen .

222
 7.9 Tib ia l co rre ct io n o s t e o t o m y (u n k n o w n u n ila t e ra l b o n e m a lfo rm a t io n )

5 Po s t o p e ra t ive ca re a n d re h a b ilit a t io n

Despite th e two osteotom ies, weigh t bearin g was allowed after After n ail rem oval, refractu re at th e distal level was seen . In
2–3 weeks. th e m ean tim e th e patien t h ad several café-au -lait spots, an d a
n eu ro brom atosis type I was d iagn osed.
Healin g h ad still n ot led to com plete con solidation after th ree
m on th s. Ou r treatm en t of ch oice in su ch a situ ation is a m icrovascu lar
bu lar tran splan t. Th is operation was perform ed th ree years
Th erefore, th e n ail was left in place for 1 years. after th e rst su rger y.

a b a b a b

Delayed h ealin g du e to
Fig 7.9 -10 a – b Fig 7.9 -11a – b Refractu re after 14 Fig 7.9 -12 a – b Rapid h ealin g was
n eu ro brom atosis type I. m on th s exactly on th e level w h ere th e ach ieved w ith plaster cast im m obiliza-
d istal pin of th e extern al xator was tion ; th e m alalign m en t was accepted at
placed 1 year ago. th is m om en t.

223
 7 Sp e cia l in d ica t io n s

6 Pit fa lls – 7 Pe a rls +

Ap p ro a ch Ap p ro a ch
An osteotom y on on ly on e level. Two osteotom ies.
No d iagn osis of d isease.

Re d u ct io n a n d xa t io n Re d u ctio n a n d xa t io n
In sertion of two n ails in to th e bon e was im possible. Th e u se of an extern al xator h avin g realized th at th e
Th e n ecessity of u sin g an add ition al extern al xator. m edu llary can al was too n arrow.
Th e possibility of u sin g two n ails.

a b

c d

Re h a b ilit a t io n Th e tech n iqu e of add ition al xation w ith a

Fig 7.9 -13 a – d
Delayed h ealin g an d con solidation . sm all extern al xator is dem on strated in th is orth oped ic
case: two-level osteotom ies of th e tibia an d in tram edu l-
lar y xation w ith ESIN tech n iqu e, add ition al sm all
extern al xator to secu re th e ax is an d th e rotation .
a – b AP view.
c– d Lateral view.

224
Appe ndix—AO com pre he nsive classi cation
of pe diatric long bone fracture s
1 In t ro d u ct io n

Th e fractu re classi cation system u sed in th is book h as cess sh ou ld be con du cted based on exam in ation of stan dard
been proposed by th e AO Ped iatric Expert Grou p (PAEG) in AP an d lateral pretreatm en t x-rays.
cooperation w ith AO Clin ical In vestigation an d Docu m en -
tation (AOCID) an d th e In tern ation al Work in g-Grou p for Lo ca liza t io n Mo rp h o lo g y
Paed iatric Trau m atology (IAGKT). Th is proposal for a com -
preh en sive classi cation of lon g bon e fractu res for ch ildren

- /
was developed accord in g to a strict validation process [1, 2] Bo n e Se gm
gm e n t Typ e Ch ild Se ve
ve rit
rit y Exc e p t
Exce
an d is su pported by th e AO Classi cation Su per visory Com - 1 2 3 4 1 2 3 4 EMD 1– 9 .1 .2 II– IV
IV
m ittee. A m ore detailed presen tation an d d iscu ssion of th is
proposal is presen ted by Slon go et al [3 ] an d fu rth er validation
stu dies are on goin g at th e tim e of pu blication . 4 lo n g 3 se g- 3 t yp e s 4–9 2 gro u p s
bones m e n ts p a t te rn s
Th e cu rren t classi cation proposal is based on th e Mü ller
AO Classi cation for adu lts [4] an d con siders ch ild-speci c Fig A1-1 Overall stru ctu re of th e pediatric fractu re classi ca-
relevan t fractu re featu res ( Fig A1-1). Th e classi cation pro- tion .

2 Fra ct u re , b o n e , a n d s e gm e n t

Follow in g th e Mü ller AO Classi cation for adu lts, th e bon es is fractu red, a sm all letter describin g th at bon e (ie, “r”, “u ”,
are sim ilarly coded: 1 = hu m eru s, 2 = rad iu s/ u ln a, 3 = fem u r, “t”, or “f”) sh ou ld be added after th e segm en t code (eg, a code
4 = tibia/ bu la. Except for Mon teggia an d Galeazzi lesion s, “22u ” iden ti es an isolated d iaph yseal fractu re of th e u ln a).
wh en paired bon es rad iu s/ u ln a or tibia/ bu la are fractu red Wh en paired bon es rad iu s/ u ln a or tibia/ bu la are fractu red
w ith th e sam e pattern (see ch ild codes in th e n ext section ), w ith d ifferen t pattern s (eg, a com plete fractu re of th e rad iu s
a sin gle classi cation code sh ou ld be u sed w ith th e severity an d a bow in g fractu re of th e u ln a), each bon e m u st be coded
code bein g th e worst of th e two bon es. Wh en a sin gle bon e separately in clu d in g th e correspon d in g sm all letter.

225
 2 Fra ct u re , b o n e , a n d s e gm e n t (co n t)

Th e segm en ts w ith in th e bon es are coded as 1 = prox im al, Malleolar fractu res in ch ild ren are coded as d istal tibia frac-
2 = d iaph yseal, 3 = d istal, bu t th eir iden ti cation d iffers from tu res (eg, th e fractu re of th e m ed ial m alleolu s is a typical
adu lts. For ped iatric lon g bon e fractu res, th e m etaph ysis is Salter-Harris III or IV fractu re of th e distal tibia coded as 43).
iden ti ed by a squ are wh ose side h as th e sam e len gth as th e
w idest part of th e grow th plate in qu estion ( Fig A1-2 ). For th e
pairs of bon es rad iu s/ u ln a an d tibia/ bu la, both bon es m u st
be in clu ded in th e squ are. Con sequ en tly, th e th ree segm en ts
can be de n ed as:
Segm en t 1: proxim al epiph ysis an d m etaph ysis (squ are)
Segm en t 2: diaphysis
Segm en t 3: distal m etaphysis (squ are) an d epiph ysis

1 2 3 4
Hu m e ru s Ra d iu s/ Uln a Fe m u r Tib ia / Fib u la

E = Ep ip h ysis
1 = Pro xim a l

M = Me ta p h ysis

2 = Sh a ft
D = Dia p h ysis

M = Me ta p h ysis

3 = Dis ta l
a E = Ep ip h ysis b

Fig A1-2 a – b Th e m etaph ysis is iden ti ed by a squ are wh ose squ are. Th e squ are pattern s are copied on to a tran sparen cy
side h as th e sam e len gth as th e w idest part of th e bon e ph y- sh eet an d applied over th e x-ray for m ore reliable an d accu rate
sis on th e AP rad iograph ic view. For th e pairs of bon es ra- d iagn osis.
d iu s/ u ln a an d tibia/ bu la, both bon es m u st be in clu ded in th e

2 26
 Ap p e n d ix—AO co m p re h e n s ive cla s s ifica t io n o f p e d ia t ric lo n g b o n e fra ct u re s

3 Fra ct u re t yp e

Th e origin al severity cod in g A-B-C u sed in adu lts [4] is re- tu res are iden ti ed by th e position of th e squ are; th e cen ter of
placed by a classi cation of fractu res accord in g to diaph ysis th e fractu re lin es m u st be located in th e squ are ( Fig A1-2 ). Th is
(D), m etaph ysis (M), an d epiph ysis (E). Th e m ost com m on squ are de n ition is n ot applied to th e prox im al fem u r wh ere
fractu re types in ch ildren are th e sh aft fractu res (segm en t m etaphyseal fractu res are located between th e ph ysis of th e
2), an d th e m etaph yseal type (segm en ts 1 an d 3). Use of th e h ead an d th e in tertroch an teric lin e (see exception code). In
E-M-D cod in g iden ti es in traarticu lar an d extraarticu lar applyin g th e squ are de n ition , m isclassi cation can occu r if
fractu res w ith ou t am bigu ity sin ce epiph yseal fractu res are th e rad iological view is n ot strictly on th e AP plan e, or th e
in traarticu lar fractu res by de n ition . Th e m etaph yseal frac- bon es are an gu lated in th e fron tal plan e.

4 Ch ild co d e

Speci c ped iatric featu res (also called “ch ild pattern s”) are
tran sform ed in to a “ch ild code”. Relevan t ch ild pattern s are
speci c to on e of th e fractu re types E, M , or D, an d h en ce
grou ped accord in gly.

Th e Salter-Harris classi cation of epiph yseal factu res leads

to th e ch ild codes E/ 1 to E/4. Oth er ch ild codes E/5 to E/ 9
are u sed to iden tify Tillau x fractu res (E/5), triplan e fractu res
(E/6), in traarticu lar ligam en t avu lsion s (E/ 7), ake fractu res E/ 1 E/ 2 E/ 3 E/ 4
(E/8), an d oth er fractu res th at m ay n ot belon g to an y of th e
oth er categories (E/ 9) ( Fig A1-3 ).

E/ 5 E/ 6 E/ 7 E/ 8

Fig A1-3 De n ition of ch ild pattern s for epiph yseal fractu res.

2 27
 4 Ch ild co d e (co n t )

Th ree ch ild pattern s are iden ti ed for m etaph yseal fractu res,
ie, th e bu ck le, toru s or m etaph yseal green stick fractu res
(M / 2), com plete fractu re (M / 3), an d m etaph yseal osteoliga-
m en tou s, m u scu loligam en tou s avu lsion or on ly avu lsion in -
ju ries (M/ 7) ( Fig A1-4 ).

a M/ 2 M/ 3 M/ 7

Ch ild pattern s w ith in segm en t 2 (d iaph yseal fractu res) are

presen ted in Fig A1-6 . Th ey in clu de bow in g fractu res (D/1),
green stick fractu res (D/ 2), com plete tran sverse fractu res
(an gle <30° = D/4), com plete obliqu e/spiral fractu res (an -
gle >30° = D/5), Mon teggia lesion s (D/6), an d Galeazzi le-
sion s (D/ 7). A 30° an gle sh ou ld be applied to th e x-rays for <_ 3 0 °
m ore reliable classi cation . Sim ilarly, th e code / 9 sh ou ld
be u sed for fractu res th at m ay n ot belon g to well-de n ed
categories.

b D/ 2
D/ 1 D/ 4

> 30°

c D/ 5 D/ 6 D/ 7

Fig A1-4 a – c
a Pattern s in m etaphyseal fractu re.
b – c Diaph yseal fractu re pattern s.

228
 Ap p e n d ix—AO co m p re h e n s ive cla s s ifica t io n o f p e d ia t ric lo n g b o n e fra ct u re s

5 Fra ct u re s e ve rit y co d e

Grad in g of fractu re severity is con sidered im portan t be- sim ple (.1), an d wedge/com plex (partially or totally u n stable
cau se of th e n eed to in vestigate th e in d ication s for variou s fractu re w ith 3 or m ore fragm en ts in clu din g a fu lly separated
m eth ods of osteosyn th esis. Th is code distin gu ish es between fragm en t) (.2).

6 Exce p t io n s a n d a d d it io n a l co d e s

Not all ped iatric fractu res can sim ply be classi ed accordin g Radial n eck fractu res (21-M / 2 or / 3, or 21-E/1 or / 2; see
to th e above system , an d so a few add ition al de n ition s an d Fig A1-6 ) are given an add ition al code regard in g th e ax ial
ru les h ave been agreed u pon : deviation an d level of d isplacem en t: n o an gu lation an d n o
Fractu res of th e apoph ysis are recogn ized as m etaph yseal displacem en t (I), an gu lation w ith d isplacem en t less th an
in ju ries. h alf of th e bon e diam eter (II), an d an gu lation w ith d is-
Tran sition al fractu res w ith or w ith ou t a m etaph yseal placem en t m ore th an h alf of th e bon e d iam eter (III).
wedge are classi ed as epiph yseal fractu res. Fem oral n eck fractu res (see Fig A1-7 ). Epiph ysiolysis an d
In tra- an d extraarticu lar ligam en t avu lsion s are epiph y- epiph ysiolysis w ith a m etaph yseal wedge are coded as n or-
seal an d m etaph yseal in ju ries, respectively. m al type E epiph yseal Salter/ Harris I an d II fractu res E/1
Su pracon dylar hu m eral fractu res (code 13-M / 3; Fig A1-5 ) an d E/ 2. Fractu res of th e fem oral n eck are coded as n orm al
are given an add ition al code regard in g th e grade of d is- type M m etaph yseal fractu res: m id-cervical (I), basicervical
placem en t at 4 levels (I to IV) accord in g to von Laer [5]: No (II), an d tran stroch an teric (III). Th e in tertroch an ter ic lin e
d isplacem en t (I), d isplacem en t in on e plan e (II), displace- delin eates th e m etaph ysis.
m en t in two plan es (III), an d d isplacem en t in th ree plan es,
or n o con tact between th e bon e fragm en ts (IV). Th e fu ll classi cation code th erefore in clu des 5 or 6 fractu re
en tities depen d in g on th e u se of an exception code.

13 -M/ 3 .1

13 -M/ 3 .1-I 13 -M/ 3 .1-II 13 -M/ 3 .1-III 13 -M/ 3 .1-IV

Fig A1-5 Su pracon dylar hu m eral fractu res.

229
 6 Exce p t io n s a n d a d d it io n a l co d e s (co n t )

21-E/ 1.1 21-E/ 1.2 21-E/ 1.3

21-E/ 2 .1 21-E/ 2 .2 21-E/ 2 .3 31-M/ 2 .1-II 31-M/ 2 .1-II 31-M/ 2 .1-III

21-E/ 3 .1 21-E/ 3 .2 21-E/ 3 .3 31-M/ 3 .1-I 31-M/ 3 .1-II 31-M/ 3 .1-III

Fig A1-6 Radial n eck fractu res. Fig A1-7 Fem oral n eck fractu res.

230
 Ap p e n d ix—AO co m p re h e n s ive cla s s ifica t io n o f p e d ia t ric lo n g b o n e fra ct u re s

7 Bib lio gra p h y

[1] A u d igé L, Hu n t e r J, We in be rg A , e t al (2004) [4] Mü lle r M , N azarian S (1990)

Developm en t an d evalu ation process of a paediatric The comprehensive classi cation for fractures of long bones.
lon g-bon e fractu re classi cation proposal. European Berlin Heidelberg New York: Sprin ger Verlag.
Journal of Trauma; 248 –254. [5] vo n Lae r L (2001)
[2] A u d ige L, Bh an d ari M , Han so n B, e t al (2005) Fractures and dislocations during growth.
A Con cept for th e Validation of Fractu re Classi cation s. Stu ttgart New York: Georg Th iem e Verlag.
J Orthop Trauma; 19:40 4 –409.
[3 ] Slo n go T, A u d igé L, Sch licke w e i W, e t al (2006)
Developm en t an d validation of th e AO ped iatric
com preh en sive classi cation of lon g bon e fractu res by
th e Ped iatric Ex pert Grou p of th e AO Fou n dation in
collaboration w ith AO Clin ical In vestigation an d
Docu m en tation an d th e In tern ation al Association for
Ped iatric Trau m atology.
J Pediatr Orthop; 26:43 –49.

2 31
 How to use the DVD

DVD

Th is DVD is an in tegral part of th e book. It provides clin ical videos an d

an im ation s wh ich , com bin ed w ith th e book itself, m ake th e in stru ctive
con ten t easier to u n derstan d.

Na viga t io n

DVD start-u p screen : th e d isc is clearly stru ctu red w ith option s for work-
sh op an d clin ical reality.

Th e DVD’s m ain m enu w ill sh ow w h ich worksh op su bject is com plem en -

ted by a clin ical video. Th e video m ay th en be ru n by sim ply selectin g it
in th e m en u .

232
 Co n t e n t

Wo rk s h o p Clin ica l vid e o

Dem on stration of th e stan dard su rgical tech n iqu e ESIN: 10-year-old ch ild w ith fem oral sh aft fractu re
for elastic stable in tra m edu llar y n ailin g (ESIN) Departm en t of Pediatric Su rgery
w ith th e titan iu m elastic n ail (TEN) presen tin g Un iversity Ch ild ren ’s Hospital Bern , Sw itzerlan d
both th e an tegrade an d retrograde approach es to
fem oral sh aft fractu res.

Also sh ow n :
Properties of th e n ails
Biom ech an ics of ESIN
In stru m en t set for TEN system

DVD s ys t e m re q u ire m e n t s

DVD p la ye r
Th is DVD can be played on m ost h om e DVD players.

Co m p u te r
You can view th e DVD on you r Win dow s or Macin tosh Com pu ter.
An y m ach in e th at is DVD capable w ill play AO Teach in g Videos.
Requ ires DVD d rive, DVD decoder, an d DVD player software.

23 3