The document discusses intramedullary fixation of diaphyseal fractures in children. It begins by providing background on the history and development of intramedullary fixation techniques. It then describes how pediatric bone differs biomechanically from adult bone. The document outlines the unique fracture patterns seen in children and discusses the biomechanics of rigid versus flexible intramedullary fixation. It provides indications and contraindications for intramedullary fixation in children. The surgical technique and advantages of flexible intramedullary nailing are summarized, along with potential complications.

1. ‫الرح‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬‫يم‬

2. Intramedullary Fixation of
Diaphyseal Fractures in
Children

3. BY
AHMED MOHAMMED
KHALIFA
MASTER DEGREE
ORTHOPEDIC SURGERY
TANTA UNIVERSITY
2009

4. Introduction
 Küntscher was the one who pioneered the intramedullary
concept
 The so called alignment nailing technique was widely
used by Rush after World War II.
 Bundle nailing for metaphyseal fractures using two, three,
four, or even more thin elastic nails was widely used by
Hackethal &Ender.
 In the late 1970, Dr. Jean-Paul, Prof. Prévot (Head of the
Department of Pediatric Orthopedics, University Hospital,
Nancy) perform first flexable intramedullary nailing.

5. Pediatric Biomechanics
A child’s bone, differs from adult bone in many
ways:
1. It is more porous (areolar tissue), it has a lower
mineral content (softer), and is therefore, not as
strong as that of an adult.
2. On the other hand, owing to its higher water
content,it exhibits greater plasticity and
elasticity.
3. It has a thicker periosteum and well
vascularized.

6. Unique fracture paterns in
children are:
 Green stick fracture
 Buckle fracture
 Bowing fracture
 Hairline fracture
In addition to:
 Spiral fracture
 Oblique fracture
 Transverse/oblique fracture with or without butterfly
fragment.
 Comminuted fracture.

7. Biomechanics of
Intramedullary fixation(IMF)
Types of IMF:
Rigid(IMN,K.W,Rush pin)
Flexable Intramedullary Nail(FIN)

8.  The primary goal of IMF is:
rapid restoration of function. However, there is one major difference:
with FIN, restoration of function is due to rapid bone healing
through optimal development of the periosteal callus, whereas with
rigid fixation, is due to the artificial stiffness provided by the device.
 It is important to stress the difference between rigid and elastic
fixation:
• Rigid Intramedullary nail: due to the rigidity of the constuct that is
critical to “primary bone union” and “cortical callus” formation, no
external callus can develop because response is abolished. The
appearance of external callus is even considered as evidence of
technical failure.
• Elastic Intramedullary fixation: contrary to rigid fixation, elastic
fixation needs some degree of relative movement to promote
formation of the external callus, which is the physiological callus
that forms most rapidly, and has the highest biomechanical
strength.

9. INDICATIONS OF IMF
 Fracture Fixation(femur, tibia,fibula,metatarsals ,metacarpals,
radius ,ulna, humerus &phalanges)
 In Ilizarov Bone Lengthening.
 Treating pathological fractures and protecting a weakened bone
area(Osteogenesis Imperfecta, C.P and Neuromuscular Diseases)
 Correction of Deformities in Children.
 Osteotomies(Femoral&tibial).
 Arthrodesis.
 With fibular grafting in limb salvage surgery &tumor surgery.

10. Contraindications
 Type III open fractures
 Floating jonts with neuro vascular injury
 Difficult Reduction and Instability

11. ADVANTAGE
 Eliminate the risks (i.e., deep infection or nonunion)
associated with traditional operative treatments.
 Avoid the scars that are inevitable with open
surgery, and even the risks of blood transfusion.
 Minimize the overgrowth that follows pediatric bone
fractures by quickly restoring the patient to normal
function
 Healing period is very short because it dose not
affect endosteal circulation

12. Stainless Steel or Titanium?
 Both stainless steel and titanium are suitable
for children, whereas stainless steel is
definitely the best choice in adolescents
because stainless steel offers greater stiffness
than titanium, and its elastic restoring force is
twice higher than that of titanium.
 stainless steel is cheaper than titanium

13. of FINSurgical Technique
 This can be performed using an antegrade technique OR
retrograde technique.
 Bipolar construct OR Unipolar construct
 Nail diameter
 0.4 of diameter of medullary canal in lower limb
 0.33 of diameter of medullary canal in upper limb

15. Nail contouring
The two nails have opposing
curves.
The radius of curvature must be
about 50–60 times greater than the
diameter of the nail.The apex of the
curve must be located at the fracture
site, here, in the middle third of the
bone

16. Dedicated Instruments

17. Surgical Technique

19.  Nail contouring is most useful to control the corrective
forces, and adjust them according to local stresses.
 Varus/valgus angulation can be addressed by directing
the nail tips medially or laterally to counter the
angulation forces.
 A varus angulation can be corrected by directing the nail
tip laterally, whereas a valgus angulation can be
corrected by directing the nail tip medially.
 Similarly, in the sagittal plane, a recurvatum angulation
can be corrected by directing the nail tips posteriorly,
and a flexion angulation by directing the nail tips so that
the concave sides face anteriorly

20. Ideally, at the end of the procedure, one
should have two nails with opposing
curves. The concavities should face each
other, and the apexes of the curves should
be located at the fracture site. Thus, both
nails cross each other proximal and distal to
the fracture

26. Rehabilitation
 Spontaneous recovery of full range of motion is
consistently observed after FIN.
 In simple fractures, rehabilitation does not play an
important role: it just helps the child to rapidly recover full
independence. However, in patients with associated
injuries or complications, which may result in functional
impairment, rehabilitation is necessary.
 FIN is particularly well suited for children who poorly
tolerate nonoperative treatments and prolonged
immobilization: it carries a very low risk of cutaneous and
orthopedic complications, and has a low potential for
functional impairment, which may sometimes be life
threatening.

27. Complications Of FIN
 Prominent Nail Ends
 Physeal injury
 Malunion
 Delayed Union and Nonunion
 Refractures and Recurrent Fractures
 Leg Length Discrepancy
 Osteomyelitis

28. Complications Of Rigid Intramedullary
Fixation
 If used in femur it may cause AVN of head femur or
valgus neck, however rigid Intramedullary nail fixation
through the lateral aspect of the greater trochanter in
children and adolescents is effective. It does not produce
clinically important femoral neck valgus or narrowing or
osteonecrosis of the femoral head.
 If used in metacarpals and phalenges,it may cause stiff MP
or IP joints.
 May affect endosteal circulation.

29. Radiological Examples

31. THANK YOU