Elastic stabile intramedullary nailing (ESIN) of diaphyseal femur fractures in children and adolescents: A strobe-compliant study

Elastic stabile intramedullary nailing (ESIN) is a well-established method to stabilize diaphyseal fracture of the femur (DFF) in children. We aimed to evaluate the minimal medullary canal diameter (MMCD) of the fractured femur relative to the diameter of the nails. We also analyzed the real anteversion angle (AVA) of the affected femur in comparison to the healthy femur. We retrospectively reviewed the medical records and plain X-ray images of children aged 2–15 years treated with ESIN for unstable femoral shaft fractures between 2004 and 2012. We measured MMCD on preoperative plain X-ray images. Nail diameter (ND) and any postoperative complications were extracted from the medical records. At follow-up conducted at a median of 40 months (range: 4–103 months) after the operation, we obtained Dunn X-ray images of both hips. Particular emphasis was placed on postoperative torsional differences in relation to age, weight, and maturity of the growth plate. We analyzed the relationship between postoperative rotational malalignment and the ratio of ND to MMCD. Median age of the 22 children at the time of injury was 7.5 years (range: 2–15 years). Median body weight was 25 kg (range: 13–57 kg). Median MMCD amounted to 8.6 mm (range: 5.5–11.0 mm). Median ND/MMCD was 36.9% (range: 27.3%–47.4%). Radiological analyses revealed a median of 27.0° (range: −22.0° to +49.0°) of real AVA in the affected leg and 32.5° (range: 18.0°–48.0°) in the healthy leg. Three children (13.6%) experienced a grade III complication (Clavien–Dindo classification of surgical complications; CDCSC). Two of these children suffered retrotorsion of the femoral neck, while the third child experienced diminished anteversion. Overall, 3 of 22 children (13.6%) suffered a CDCSC-grade III complication (i.e., retrotorsion of the femoral neck in two children and diminished anteversion of the femoral neck in one child). We recommend obtaining Dunn images at the end of the operation to confirm correct rotational alignment after stabilization with ESIN. Further prospective studies are required to confirm our findings.