1. Flexible Intramedullary Nailing or External Fixation for Pediatric Femoral Shaft Fractures Soo-Sung Park M.D., Jae-Bum Park M.D. Department of Orthopaedic Surgery, Ulsan University College of Medicine Asan Medical Center

2. Treatment of Pediatric Femoral Shaft Fracture Conservative treatments Immediate or delayed hip spica cast Operative treatments External Fixator(EF), Compression Plate, Flexible Intramedullary Nailing(FIN), Rigid Intramedullary Nailing Early mobilization Psychological, social, educational, economic advantage Less deformity, less LLD

3. External fixation (EF) Minimal invasive with little blood loss Can be applied quickly Allow to access to wounds and soft tissues Allow the patient to be mobilized However Delayed Union Pin tract infection Refracture Blasier et al, JPO 1997,17:342-346

4. Flexible Intramedullary Nailing (FIN) Relatively rapid fracture stabilization Early patient mobilization Potentially anatomic fracture union Small incision, minimal blood loss Excellent results with no major complications Heinrich et al. JPO 1994 Flynn et al. JPO 2001 Luhmann et al. JPO 2003

5. Purpose of this study To compare the outcome of flexible intramedullary nailing and external fixation for the treatment of pediatric femoral shaft fractures

6. Materials 1999. 6 ~ 2005. 4 EF or FIN with Follow-up > 1yr (37pts.) Patients (5pts.) with concomitant fractures of L/E were excluded 32 patients (M:F = 22:10)

7. Materials NoAge (yr)Mean follow-up (mo) FIN226.2 (1.5~12)22.2 (13.1~56.5) EF107.5 (3.0~10)26.1 (13.9~64.8) FIN : 18/22 (2003~2005) EF : 8/10 (1999~2001)

8. location pattern proximalmiddledistal trans- verse obliquespiral commi- nution FIN51348455 EF1722413 Open fracture : 1 case (in EF group) Multiple trauma : FIN – 4 cases (18%) EF – 3 cases (30%) Fracture Characteristics

9. Flexible Intramedullary Nailing Closed reduction (mini-open : 5 cases) Retrograde insertion Two elastic nails Implants TEN : 6 cases Khai nail : 13 cases Steinmann pin : 3 cases

10. Flexible Intramedullary Nailing Additional immobilization (3~5 wks) Hip spica cast (one & half) : 18 cases Knee immobilizer : 3 cases Long leg splint : 1 case Implants was removed routinely after bony union

11. External Fixation Closed reduction Apposition End to end : 5 cases Side to side : 5 cases Implant removal

12. Evaluation Hospital stay, Operation time, Hospital costs Time interval between OP & RI LLD, malalignment ROM Complications Wilcoxon-Mann-Whitney test

13. TEN outcome scoring Excellent ResultSatisfactory ResultPoor Result LLD 2.0 cm Malalignment 5 degrees 10 degrees >10 degrees Pain none none present Complications none minor & resolved major and/or lasting morbidity Flynn et al. JPO 2001

14. Results

15. Days of hospital stay * P < 0.01

16. Operation time * P <0.05

17. Hospital Costs Won FIN1,300,000 (57~310 만 ) EF2,750,000 (120~420 만 ) * P <0.05

18. Implant removal Days (after Op) FIN107 EF84 P = 0.15 (>0.05)

19. Leg length discrepancy FIN 2.6mm (-12~11mm) EF 9.3mm (2~29mm) >20mm : 1 case * P <0.05

20. Malalignment (Angular deformity) FIN - No significant deformity EF - 1 valgus deformity Degloving injury Open fracture PO 18M

21. Range of motion (ROM) Full ROM at final F/U in both groups

22. Complications FIN group Nail erosion : 4 cases Temporary peroneal nerve palsy : 1 case Refracture : 1 case EF group Deep pin tract infection : 3 cases (adm.& IV antibiotics) Refracture : 1 case Pin breakage : 1 case

23. TEN outcome scoring Excellent ResultSatisfactory Result Poor Result FIN (N=22) 17 4 1 EF (N=10) 4 3 3 Poor result : FIN – 1 refracture : EF – 1 refracture, 1 LLD >2cm, 1 valgus DF

24. Summary Flexible intramedullary nailing Shorter hospital stay Lower hospital cost External fixation Shorter operation time High rate of pin tract infection & complication  FIN than EF due to incidence & severity of complication

25. Discussion EF or FIN Prospective, randomized study 20 fractures (10 fractures each) FIN > EF (open or severely comminuted fx.) : WB, ROM, return to school, Cx rate Bar-on E, Sagiv S, Porat S JBJS(B) 1997

26. Conclusions Recommand Flexible intramedullary nailing for most pediatric femoral shaft fractures Reserve external fixation for the length-unstable (sig. comminution), open, some very proximal or distal fractures.

27. Thank you for your attention!