Was tun, wenn die elastisch-stabile intramedulläre Nagelung (ESIN) an ihre Grenzen stößt?

Abstract

Background: Elastic stable intramedullary nailing (ESIN) has developed into the gold standard of treatment for femoral fractures in childhood worldwide. It is a safe and efficient procedure if the biomechanical and technical prerequisites are adhered to. Objectives: The age of the child, the diameter of the bone marrow cavity in relation to bone thickness and high body weight can be limiting factors of ESIN. In the same manner the quality of treatment is influenced by the complexity of the fracture in combination with technical shortcomings. The simple application of ESIN can induce an inattentive approach and in particular neglecting the indispensable adherence to biomechanical principles. The major problems on the part of surgeons are an insufficient analysis of the fracture, the resulting relatively false indications and non-compliance to technical prerequisites. This could be due to incorrect selection of implant thickness and entry site, lack of internal clamping and 3-point contact, corkscrewing of nails, nail perforation at the proximal end of the femur and fragmentation of additional bone wedges. Optimal treatment of adolescents: In order to fulfill these conditions, a method adapted to age, weight and bone morphology must be selected with which the fracture can be securely, stably and definitively fixed. The treatment should be carried out in a manner which is suitable for children and adolescents and should, therefore, be as atraumatic as possible. Malpositioning cannot be tolerated because sufficient correction potential is no longer present. The osteosynthesis should be capable of withstanding pressure. Conclusion: The ESIN procedure should only be used in children who still have open epiphyseal plates. The axial load can be increased several-fold by the use of end caps. In cases of insufficient experience with ESIN, problematic circumstances of the patient and/or the fracture, plate osteosynthesis is one of the foremost alternatives in order to achieve a secure and sufficient stabilization of the fracture.