FUNCTIONAL OUTCOME ANALYSIS OF TIBIA FRACTURE MANAGED BY

TENS NAILING IN PAEDIATRIC AGE GROUP

2. Author ,Co-Author ,HOD and Guide details

Name
Name Designation Department Institution Name
type
GOVT.MOHAN
KUMARAMANGALAM
POST
1. Author DR.S.SENTHIL RAJA ORTHOPAEDICS MEDICAL COLLEGE
GRADUATE
AND
HOSPITAL,SALEM
GOVT.MOHAN
KUMARAMANGALAM
2. Co- SENIOR
DR.T.SENTHIL KUMAR ORTHOPAEDICS MEDICAL COLLEGE
Author RESIDENT
AND
HOSPITAL,SALEM
GOVT.MOHAN
SENIOR KUMARAMANGALAM
3. Co-
DR.S.SYED NASER ASSISTANT ORTHOPAEDICS MEDICAL COLLEGE
Author
PROFESSOR AND
HOSPITAL,SALEM
GOVT.MOHAN
KUMARAMANGALAM
4. Co- ASSISTANT
DR.P.PRASANNAMOORTHY ORTHOPADEICS MEDICAL COLLEGE
Author PROFESSOR
AND
HOSPITAL,SALEM
GOVT.MOHAN
KUMARAMANGALAM
ASSOCIATE
5. Guide DR.T.KARIKALAN ORTHOPAEDICS MEDICAL COLLEGE
PROFESSOR
AND
HOSPITAL,SALEM
GOVT.MOHAN
KUMARAMANGALAM
HEAD OF THE
6. HOD DR.C.KAMALANATHAN ORTHOPAEDICS MEDICAL COLLEGE
DEPARTMENT
AND
HOSPITAL,SALEM

3. Abstract and Keywords

ABSTRACT Background: Closed reduction and cast application is considered the first line of
treatment for tibial shaft fractures in children. Over the past few decades, management of paediatric
tibial shaft fractures has shifted more towards the operative intervention owing to less
immobilization, faster recovery, shorter rehabilitation period, prevention of joint stiffness and less
psychological impact to the children. Flexible intramedullary nails have been found to fulfil all the
above-mentioned advantages and they also maintain a good alignment and rotation at the fracture
site. Methods: A prospective and retrospective study was performed on paediatric tibial shaft
fractures fixed with titanium elastic nailing system. We assessed the fracture alignment, fracture
union time, motion of the knee joint, infection, delayed union, non-union, and limb length
discrepancy at the follow-up visits. The outcomes were classified as excellent, satisfactory or poor as
per the Flynn scoring for flexible elastic nailing fixation. Results: We observed 10 patients admitted
in paediatric age group between 6-13 years had tibial fracture managed by TENS nailing. All
patients achieved union at a mean of 12 weeks. At last follow-up, the result was excellent in 6
patients and satisfactory in 4 patients. 6 patients had less than 5-degree angulation and 4 patients
had 5–10-degree angulation. The most common complication was irritation at nail entry site. One
case had delayed union and one case had limb length shortening Conclusion: Titanium elastic nail
fixation is an effective and reliable method for management of tibial shaft fractures in children. It
allows rapid healing of tibial shaft fractures with an acceptable rate of complications. Keywords:
Elastic intramedullary nail; paediatric tibia fracture; titanium elastic nails

4. Introduction

INTRODUCTION Tibia shaft fractures are the third most common fracture in children. They
account for 10-15% of paediatric fractures [1]. Closed reduction and cast application is the main
treatment modality for paediatric tibial shaft fractures. Elastic nails are intra medullary devices and
allow early mobilization. Micromotion at the fracture site enhances the bone healing. Titanium
elastic nails achieved biomechanical stability from its prebend ‘C’ configuration which provides
stable three-point fixation and acts as an internal splint [2]. Elastic intramedullary nailing in long
bone fractures in children has gained popularity because of its high effectiveness and less
complication rate [3-5]. The advantages of elastic intramedullary nails include closed insertion, with
preservation of fracture hematoma, minimal risk of fracture site infection, and the most importantly,
a physeal sparing entry point. Other advantages are minimal soft tissue injury, early mobilization,
low infection rates [3-5] and shorter hospital stays. The disadvantages include less stability
compared with other fixation methods and need of nail removal in future [6].

5. Aim and Objectives

AIM AND OBJECTIVE Our aim to analyse the functional outcome of tibial fracture managed by
TENS nailing in paediatric age group by using FLYNN scoring system.

6. Review of Literature

REVIEW OF LITERATURE • Flynn JM, Hresko T, Reynolds RA, Blasier RD, Davidson R, et al.
(2001)-Titanium Elastic Nails for Paediatric Femur Fractures: A Multicentre Study of Early Results
with Analysis of Complications - TENS may prove to be the ideal implant to stabilize many paediatric
femur fractures, avoiding the prolonged immobilization and complications of traction and spica
casting. • Goodwin RC, Gaynor T, Mahar A, Oka R, Lalonde FD (2005)-Intramedullary Flexible Nail
Fixation of Unstable Paediatric Tibial Diaphyseal Fractures- , flexible intramedullary nail fixation is a
safe, reproducible, and reliable treatment modality for children with unstable tibial shaft fractures. •
Vallamshetla P, De Silva U, Bache CE, Gibbons PJ (2006)- Flexible intramedullary nails for unstable
fractures of the tibia in children. Fixation with flexible intramedullary nails in diaphyseal fracture
shaft of tibia in paediatric age group is simple, effective, minimally invasive procedure with short
hospital stay and having good outcome. • Ahmed EKF, Zakaria B, Hadhood M, Shaheen A (2014)-
Management of diaphyseal tibial fracture in paediatric by elastic stable intramedullary nails. Elastic
intramedullary nailing is a safe and reliable treatment method for paediatric tibial fractures. It
provides stable fixation and allows rapid healing of fractures with minimal complications. • Onta PR,
Thapa P, Sapkota K, Ranjeet N, Kishore, et al. (2015)- Outcome of diaphyseal fracture of tibia
treated with flexible intramedullary nailing in paediatric age group: A prospective study. • Heo J, Oh
CW, Park KH, Kim JW, Kim HJ, et al. (2016) Elastic nailing of tibia shaft fractures in young children
up to 10 years of age- Even with open fractures or soft tissue injuries, elastic nailing can achieve
satisfactory results in young children, with minimal complications of delayed bone healing, or
infection.

7. Material and Methods

MATERIALS AND METHODS This was a prospective and retrospective analytical study
performed from Nov 2020 to Nov 2022. Ethical clearance was taken from the Ethical Committee.
INCLUSION CRITERIA: 1)Paediatric age group 6-13 years patient had closed diaphyseal tibia
fractures, 2) Both sex , 3/Grade I, II compound diaphyseal tibia fracture in paediatric age group 6-13
years. EXCLUSION CRITERIA: 1)Tibial fractures in children of age less than 6 years and in those of
more than 13 years, 2)Grade III compound diaphyseal tibia fracture in paediatric age group 6-13
years, intra articular fracture, 3) patient medically unfit for surgery. 10 patients were included in
our study. All of these patients were operated under general anaesthesia/regional anaesthesia. TENS
NAIL IMAGE (figure 1): The nails were manually pre-contoured into C shape (figure 2) to achieve
intramedullary three-point fixation. 45 degrees bent was given to the nails’ tip for easy negotiation
across the fracture site. NAIL DIAMETER CALCULATION BY USING FLYNN FORMULA (figure 3)
Nail diameter = 0.4 X narrowest diameter of medullary canal. INSTRUMENT USED:(figure 4-5) • A-
2.5–4.0 mm elastic nails • B- End caps and insertion device • C – Inserter • D- Awl or drill • E-
Hammer • F- Extraction plier • G- Nail cutter SURGICAL TECHNIQUE SKIN INCISION: An incision
of size around 2 cm was made either lateral or medial side of the proximal leg. (Figure 6) ENTRY
POINT:(figure 7) The medial and lateral entry points are 2 cm distal to the proximal tibial physis,
avoiding the cartilage of the apophysis. The lateral entry point may be more anterior due to muscle
coverage. Place the drill or awl directly onto the bone and perforate the near cortex, under direct
vision, perpendicular to the bone. When the medullary canal is entered, angle the drill or awl handle
45° to the shaft axis (figure 8). Avoid perforating the far cortex. NAIL INSERTION: (figure 9) Insert
the nail through one of the entry points into the intramedullary canal and advance it towards the
fracture site with gentle oscillating movements under c arm guidance in both AP and lateral view .
Then the second nail was inserted by similar method as described above. We advanced the nails
distally till the tips were just proximal to the distal tibial physis. Proximally, around 1 cm of the nails
was left outside the cortex for removal. Special attention is to be paid to ensure that both the nails
are of the same size to avoid differential loading over opposite cortices which may lead to angular
deformity. An above knee posterior slab was applied at the end of the surgery. CASE
SCENARIO:(figure 10) AFTER TENS NAIL EXIT: (figure 11) The posterior slab was removed after
three weeks post-operatively and the patients were asked to walk with partial weight bearing over
the affected leg. Patients were evaluated at three weeks, six weeks, three months, six months and
one year post surgery to assess the fracture alignment, fracture union time, motion of the knee joint,
infection, delayed union, non-union, and limb length discrepancy.

8. Results (Including Observations)

RESULT The master chart of our patients is mentioned in (table 1). The demographic data of our
patients is mentioned in [Table 2], mechanism of injury in pie chart (chart 1) and the fracture
pattern in bar chart (chart 2). The average age of patients in our study was 10.3 years and the
average time taken for fracture union was 12 weeks. The complications which were noted in our
study are mentioned in [Table 3]. Table 1: Master chart Table 2 : Demographic data chart 1 :pie
chart - mechanism of injury chart2 : bar chart -fracture pattern Table 3: Complication after surgical
interventions Table 4: Flynn scoring system On assessing our treatment outcomes according to the
Flynn scoring system [7]. we achieved 6 (60%) excellent results, 4 (40%) satisfactory results and no
poor result [Table 4). The satisfactory results found in our study were either due to the nail entry
site skin irritation, limb shortening, delayed union.
9. Discussion

DISCUSSION Titanium elastic nails (TENS) have recently been recognized as a very important
treatment option in closed diaphyseal tibia fracture and GRADE I, II compound diaphyseal tibia
fractures in paediatric age group because of the several advantages provided by it, which include
applicability in open fractures, minimal scar formation and providing excellent overall outcomes in
tibia shaft fractures in the paediatric age group. TENS have been shown to not only maintain the
alignment at the fracture site but also, they are capable of adjusting the rotation of the limb while
treating these fractures. In addition to providing good stability, these nails also provide some
amount of elasticity and micro-motion at the fracture site that actually stimulates formation of callus
and fasten the union process. The possibility of surgical site infection is also significantly reduced
because of the need for very small incisions for such surgery. In our study, we could achieve an
excellent result in 60% of our patients and a satisfactory result in 40% of our patients. No poor
result was noted. The most common complication that has been reported with TENS nail is
prominence and skin irritation at the nail entry site. Nail prominence can lead to more serious
complications like superficial or deep infection, bursitis, skin breakdown, repositioning and the need
for premature implant removal with subsequent risk of re-fracture. The worst complication can be
extension of infection to the diaphysis leading to osteomyelitis. There were seen 1 (10%) case of
delayed union and no case of malunion, non -union in our study. Both delayed union and non-union
are found to be uncommon after TENS in long bones of the lower limbs. Delayed union or non-union
can also be caused by infection at the fracture site secondary to the open wounds. Limb length
discrepancy has also been reported following tibia shaft fractures. In our study, 1(10%) patient were
seen to have a limb length shortening of 5 mm. No patient had limb lengthening. The patient with
post-op shortening was a case of type II open fracture. Usually shortening is encountered secondary
to comminution and lengthening secondary to physeal stimulation because of hypervascularity
during healing of the fracture. No case of compartment syndrome was observed in our study. None
of the patients in our study required any secondary surgical intervention or re-admission following
discharge, except for nail removal. There were some limitations in our study. It included a small
number of patients. There was no control group and we did not compare other modalities of
treatment

10. Summary and Conclusion

CONCLUSION Titanium elastic nailing system is a simple, reliable, rapid and effective method
for the management of tibia shaft fractures in the age group of 6 to 13 years. It involves indirect
healing (fracture hematoma preserved), lesser blood loss, shorter surgical time, decreased
hospitalization, early mobilisation, early union. Though it may involve some complications, most of
them are avoidable as well as manageable with careful precautions taken intra-operatively.

11. Bibliography

BIBLIOGRAPHY 1. Santili C, Gomes C, Waisberg G, Braga S, Lino JW, et al. (2010) Tibial
diaphyseal fractures in children. Acta Ortop Bras 18: 44-48. 2. Ligier JN, Metaizeau JP, Prevot J,
Lascombes P (1985) Elastic stable intramedullary pinning of long bone fractures in children. Z
Kinderchir 40: 209-212. 3. O’Brien T, Weisman DS, Ronchetti P, Piller CP, Maloney M (2004)
Flexible titanium elastic nailing for the treatment of the unstable pediatric tibial fracture. J Pediatr
Orthop 24: 601-609. 4. Kubiak EN, Egol KA, Scher D, Wasserman B, Feldman D, et al. (2005)
Operative treatment of tibial fractures in children: are elastic stable intramedullary nails an
improvement over external fixation? J Bone Joint Surg Am 87: 1761-1768. 5. Sankar WN, Jones KJ,
Horn D, Wells L (2007) Titanium elastic nails for pediatric tibial shaft fractures. J Child Orthop 1:
281-286. 6. Metaizeau J (2004) Stable elastic intramedullary nailing of fractures of the femur in
children. J Bone Joint Surg Br 86: 954-957. 7. Flynn JM, Hresko T, Reynolds RA, Blasier RD,
Davidson R, et al. (2001) Titanium elastic nails for pediatric femur fractures - a multicentre study of
early results with analysis of complications. J Pediatr Orthop 21: 4-8. 8. Goodwin RC, Gaynor T,
Mahar A, Oka R, Lalonde FD (2005) Intramedullary flexible nail fixation of unstable pediatric tibial
diaphyseal fractures. J Pediatr Orthop 25: 570-576. 9. Vallamshetla P, De Silva U, Bache CE, Gibbons
PJ (2006) Flexible intramedullary nails for unstable fractures of the tibia in children. An eight-year
experience. J Bone Joint Surg Br 88: 536-540. 10. El-Adl G, Mostafa MF, Khalil MA, Enan A (2009)
Titanium elastic nail fixation for pediatric femoral and tibial fractures. Acta Orthop Belg 75: 512-520.
11. Ahmed EKF, Zakaria B, Hadhood M, Shaheen A (2014) Management of diaphyseal tibial fracture
in pediatric by elastic stable intramedullary nails. Menoufia Med J 27: 401-406. 12. Onta PR, Thapa
P, Sapkota K, Ranjeet N, Kishore, et al. (2015) Outcome of diaphyseal fracture of tibia treated with
flexible intramedullary nailing in pediatrics age group: A prospective study. Am J Public Health Res
3: 65-68. 13. Heo J, Oh CW, Park KH, Kim JW, Kim HJ, et al. (2016) Elastic nailing of tibia shaft
fractures in young children up to 10 years of age. Injury Int J Care Injured, pp: 832-836. 14. Carey T,
Galpin R (1996) Flexible intramedullary nail fixation of pediatric femoral fractures. Clin Orthop 332:
110–118.

12. Tables and Charts

12.1 Table TABLE 1-MASTER CHART

12.3 Table TABLE-3 COMPLICATIONS AFTER SURGICAL INTERVENTIONS

12.4 Table TABLE-4 FLYNN SCORING SYSTEM

12.5 Chart CHART 1 PIE CHART -MECHANISM OF INJURY

13. Figures and Illustrations

13.1 Figures FIGURE 1-TENS NAIL IMAGE

13.2 Figures FIGURE 2-PRE CONTOURING

13.4 Figures FIGURE 4-INSTRUMENT USED

13.5 Figures FIGURE 5- INSTRUMENT USED- NAIL CUTTER

13.7 Figures FIGURE 7-ENTRY POINT

13.8 Figures FIGURE 8-C ARM IMAGE

13.10 Figures FIGURE 10-CASE SCENARIO

13.11 Figures FIGURE 11-AFTER TENS NAIL EXIT