Early Report on Use of Titanium Elastic Nails for Pediatric Fractures
Surgeons in China proudly report their early experiences using titanium elastic nails (TENs) in children. Fractures of the proximal humerus (upper arm near the shoulder) are the main focus. Treatment of severe, displaced (separated), or irreducible (bone cannot be lined up) fractures at this site so close to the growth plate can be very challenging. The excellent results in the 25 children presented in this study are very encouraging.
Fortunately, bone fractures in children repair quickly. The already rapidly growing bone aids in this process. But a complete fracture that splinters into pieces or separates and then buttonholes (one end of the bone pops through the muscle) cannot be easily put back into place and held there until healing takes place.
That's where these titanium elastic nails come into the picture. First used in the early 1970s by a French surgeon, the technique was brought to China in 2004. At least one of the authors of this study went to France to study the Metaizeau TEN technique under Dr. Djamel Louahem.
The first case of severely displaced proximal humeral fracture in a child was treated with the TEN approach in 2006. The authors present a step-by-step description of the surgical procedures with X-rays to show the final nail placement. Holes are drilled at the bottom of the humerus and two thin nails threaded up through the bone. A special X-ray table is used to guide the surgeon.
Performing the surgery like this without a long incision is called a closed reduction. In seven of the patients, open reduction with a long incision was necessary. But the use of the titanium elastic nails was used in all 25 cases. The nails are prebent in a slight C-shape to help prevent rotation of the bone and displacement of the healing fracture.
Since that first case in 2006, 25 children ages six to 15 have been treated this way. Tumbling and traffic accidents accounted for the majority of cases. Many children now ride their bicycles to school resulting in more injuries due to car accidents than ever before.
They were all followed for up to three years. Results were reported using X-rays, presence of limb deformity, patient/family satisfaction, and shoulder range-of-motion. The X-rays could show the placement of the nails and premature (too early) closure of the growth plate. X-rays also gave the surgeons a visual picture of the fracture itself and an opportunity to measure for shortening of the bone.
How did things turn out for these children using this new treatment approach? The good news is that all fractures were completely healed in two months' time. There were no major problems or complications. Skin irritation where the end of the nail was located was reported in three children. All children achieved full shoulder range-of-motion and returned to unrestricted participation in sports.
The authors conclude the minimally invasive Metaizeau TEN approach to these upper arm fractures in growing children and teens has changed the way these injuries are treated around the world. There is no need to make repeated attempts to reduce the fracture without surgery and no need for open incision fracture reduction.
Functional results are improved because there is less risk of nerve and blood vessel injury. Being able to stabilize severe fractures also reduces the number of arm deformities and limb shortening. And finally, when compared with conservative (nonoperative) care with immobilization, this operative treatment was preferred by families. Children experienced less pain, a shorter healing time, and faster time getting back to their daily activities including recreation and sports.
Reference: Feng Xie, MD, et al. Minimally Invasive Treatment for Severely Displaced Proximal Humeral Fractures in Children Using Titanium Elastic Nails. In The Journal of Hand Surgery. December 2011. Vol. 31. No. 8. Pp. 839-846.