Intramedullary Nailing in a 13-Year-Old with Open Physis
In a 13-year-old with open physis and femoral/tibial fractures, combine external fixation with intramedullary nailing to prevent refractures and axial deformities, avoiding violation of the physis by using appropriate entry points and techniques. 1
Recommended Surgical Approach
Primary Fixation Strategy
- Combined external fixation with intramedullary fixation is the preferred method for pediatric patients with open physis, achieving 84% consensus agreement among orthopedic specialists for preventing refractures and maintaining alignment 1
- This combined approach addresses the unique challenge of maintaining stability while respecting growth plate integrity 1
Technical Modifications for Open Physis
Entry Point Selection:
- Avoid the piriformis fossa entry point for femoral nailing, as this violates the proximal femoral physis 2
- Use a trochanteric entry point for femoral shaft fractures to bypass the physis entirely 2
- For tibial fractures, use a suprapatellar approach with careful attention to avoid the proximal tibial physis 3
- The entry point should be placed at the junction of the articular surface and anterior cortex, staying clear of physeal structures 3
Nail Selection:
- Rigid locked intramedullary nails can be used safely in skeletally immature patients as young as 7.6 years when fracture configuration or patient size makes flexible nailing inappropriate 4
- Noncannulated rigid locked nails achieved 100% union rates without osteonecrosis or growth disturbance in patients aged 7.6-11.9 years 4
- Telescopic nails (Fassier-Duval) received only 21% consensus agreement for use alone, suggesting they should be combined with external fixation 1
Surgical Timing
- Perform definitive osteosynthesis within 24 hours if the patient is hemodynamically stable without severe visceral injuries 1
- Early fixation (within 24 hours) reduces ARDS and fat embolism syndrome risk, particularly critical for femoral and tibial shaft fractures 1
- If the patient has circulatory shock, respiratory failure, or severe associated injuries, use temporary external fixation first, then convert to definitive fixation once stabilized 1
Critical Technical Considerations
Avoiding Physeal Damage
- Do not cross the physis with the intramedullary nail - this is the fundamental principle 4, 2
- Use fluoroscopic guidance in both AP and lateral views throughout the procedure to confirm physis is not violated 3
- The guide pin must be placed carefully to avoid physeal injury during initial entry 3
Fracture Stability Requirements
- Only use intramedullary nailing without interlocking in fractures with demonstrated axial and rotational stability 5
- For length-unstable fractures (common in pediatric trauma), interlocking screws are mandatory 4
- The interlocking screws must also avoid crossing the physis 4
Common Pitfalls to Avoid
Inappropriate Nail Selection:
- Intramedullary rods used alone have high failure rates (67.7% primary union, 48.1% refracture rate) in pediatric populations 1
- Fixed nails like Rush rods received only 5% consensus agreement for use alone 1
Timing Errors:
- Converting from external fixation to intramedullary nailing after 2 weeks increases infection rates significantly 6
- If external fixation is used initially, convert to intramedullary fixation within 2 weeks 6
Technical Errors:
- Inadequate reduction before fixation leads to malunion and hardware failure 7
- Over-reaming in pediatric bone can compromise physeal blood supply 3
- Failure to achieve bicortical purchase with interlocking screws increases failure risk 4
Postoperative Management
- Allow immediate weight-bearing as tolerated after stable fixation is achieved 8, 7
- Provide assistive devices (walker/crutches) for the first 2-3 weeks for balance support 8
- Monitor for complications including refracture (occurs in up to 48% without combined fixation) 1
- Long-term follow-up is essential as refractures can occur years after initial union 1