Comparative analysis of different modifications of elastic nail osteosynthesis in the treatment of children with extra-articular proximal humeral fractures

Introduction The relevance of studying the treatment of proximal humeral fractures in children stems from the high incidence of fractures in this anatomical region and the absence of a standardized treatment approach. This highlights the need for further research to develop treatment protocols that account for the unique characteristics of the pediatric body and the specific features of these fracture types.

Objective of the study was to analyze and compare the outcomes of treating children with extra-articular proximal humeral fractures using double-nail versus single-nail modifications of intramedullary osteosynthesis with elastic nails.

Materials and Methods Patients were divided into two groups. The study group (n = 39) patients underwent surgical treatment with a single elastic rod while patients in the control group (n = 32) received treatment using a double-nail modification of osteosynthesis. Treatment efficacy was analyzed in both inpatient and outpatient settings with clinical, radiological, and sociological assessment methods.

Results Postoperative parameters (duration of pain syndrome, hospitalization period, return to school, and fracture consolidation time) were comparable in both groups, indicating similar efficacy of the treatment methods in these studied parameters. Statistically significant differences were observed only in operative time, directly linked to the specific surgical techniques employed in each group. The proposed method in the main study group allowed for faster surgery and did not significantly affect other key parameters of anatomical and functional recovery. Patients in both groups were satisfied with the treatment outcomes.

Discussion Unlike the conventional two-nail configuration, the single-rod approach significantly reduces operative time, thereby lowering the risks associated with anesthesia, and slightly reduces the duration of pain syndrome. The study had limitations, including a short follow-up period (no more than 12 months post-injury and 1 month post-implant removal) and a lack of differentiation between fracture configurations (metaphyseal vs. epiphyseal fractures).

Conclusion The single elastic nail osteosynthesis method provides functional recovery of the injured segment and restoration of the child’s overall activity comparable to the double-nail technique. Fracture consolidation occurs with correct fragment alignment within standard timeframes.

1. Nattuvetti PP. Treatment of humeral fractures and their consequences based on the biomechanical concept of fragment fixation. In: Nattuvetti PP, Chernyshov AA. Diagnosis and treatment of polytrauma. Moscow; 1999:169-170. (In Russ.)

2. Shore BJ, Hedequist DJ, Miller PE, et al. Surgical management for displaced pediatric proximal humeral fractures: a cost analysis. J Child Orthop. 2015;9(1):55-64. doi: 10.1007/s11832-015-0643-2.

3. Lomtatidze ES, Lomtatidze VE, Potseluyko SV, Toropov EA. Analysis of the functional results of internal osteosynthesis in fractures of the proximal humerus. N.N. Priorov Journal of Traumatology and Orthopedics. 2003;10(3):62–66. (In Russ.) doi: 10.17816/vto200310362-66.

4. Gavrilov II, Brysyuk GP, Gayduk MV, et al. Osteosynthesis of fractures of the proximal part of the humerus with plates with angular stability. Trauma. 2011;12(3):30-33. (In Russ.)

5. Bahrs C, Zipplies S, Ochs BG, et al, Weise K. Proximal humeral fractures in children and adolescents. J Pediatr Orthop. 2009;29(3):238-242. doi: 10.1097/BPO.0b013e31819bd9a7.

6. Lascombes P, Nespola A, Poircuitte JM, et al. Early complications with flexible intramedullary nailing in childhood fracture: 100 cases managed with precurved tip and shaft nails. Orthop Traumatol Surg Res. 2012;98(4):369-375. doi: 10.1016/j.otsr.2011.11.011.

7. Flynn JM, Hresko T, Reynolds RA, et al. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop. 2001;21(1):4-8. doi: 10.1097/00004694-200101000-00003.

8. Andreacchio A, Alberghina F, Canavese F. The advent of elastic stable intramedullary nailing for the treatment of long bone fractures in skeletally immature patients. Genij Ortopedii. 2021;27(4):406-412. doi: 10.18019/1028-4427-202127-4-406-412.

9. Joeris A, Lutz N, Blumenthal A, et al. The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF). Acta Orthop. 2017;88(2):129-132. doi: 10.1080/17453674.2016.1258533.

10. Kennedy CA, Beaton DE, Smith P, et al. Measurement properties of the QuickDASH (disabilities of the arm, shoulder and hand) outcome measure and cross-cultural adaptations of the QuickDASH: a systematic review. Qual Life Res. 2013;22(9):2509-2547. doi: 10.1007/s11136-013-0362-4.

11. Neer CS 2nd, Horwitz BS. Fractures of the proximal humeral epiphysial plate. Clin Orthop Relat Res. 1965;41:24-31.

12. Flynn JM, Hresko T, Reynolds RA, et al. Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop. 2001;21(1):4-8. doi: 10.1097/00004694-200101000-00003.

13. de Cort BA, Ten Duis K, Govaert GAM, IJpma FFA. Proximal humeral fractures in children: large remodeling capacity, conservative treatment. Ned Tijdschr Geneeskd. 2021;165:D5420. (In Dutch).

14. Bishop JY, Flatow EL. Pediatric shoulder trauma. Clin Orthop Relat Res. 2005;(432):41-48. doi: 10.1097/01.blo.0000156005.01503.43.

15. Dameron TB Jr, Reibel DB. Fractures involving the proximal humeral epiphyseal plate. J Bone Joint Surg Am. 1969;51(2):289-297.

16. Cruz AI Jr, Kleiner JE, Gil JA, et al. Inpatient surgical treatment of paediatric proximal humerus fractures between 2000 and 2012. J Child Orthop. 2018;12(2):111-116. doi: 10.1302/1863-2548.12.170220.

17. Chaus GW, Carry PM, Pishkenari AK, Hadley-Miller N. Operative versus nonoperative treatment of displaced proximal humeral physeal fractures: a matched cohort. J Pediatr Orthop. 2015;35(3):234-239. doi: 10.1097/BPO.0000000000000265.

18. Fernandez FF, Eberhardt O, Langendörfer M, Wirth T. Treatment of severely displaced proximal humeral fractures in children with retrograde elastic stable intramedullary nailing. Injury. 2008;39(12):1453-1459. doi: 10.1016/j.injury.2008.04.001.

19. Rowles DJ, McGrory JE. Percutaneous pinning of the proximal part of the humerus. An anatomic study. J Bone Joint Surg Am. 2001;83(11):1695-1699. doi: 10.2106/00004623-200111000-00012.

20. Wang Y, Wang Q, Yao W, et al. Kirschner wire versus external fixation in the treatment of proximal humeral fractures in older children and adolescents: a comparative study. BMC Musculoskelet Disord. 2023;24(1):899. doi: 10.1186/ s12891-023-07037-x.

21. Swarup I, Hughes MS, Bram JT, et al. Percutaneous Pinning of Pediatric Proximal Humeral Fractures. JBJS Essent Surg Tech. 2019;9(4):e33.1-6. doi: 10.2106/JBJS.ST.19.00002.

22. Hohloch L, Eberbach H, Wagner FC, et al. Age- and severity-adjusted treatment of proximal humerus fractures in children and adolescents-A systematical review and meta-analysis. PLoS One. 2017;12(8):e0183157. doi: 10.1371/journal.pone.0183157.

23. Hutchinson PH, Bae DS, Waters PM. Intramedullary nailing versus percutaneous pin fixation of pediatric proximal humerus fractures: a comparison of complications and early radiographic results. J Pediatr Orthop. 2011;31(6):617-622. doi: 10.1097/BPO.0b013e3182210903.

24. Freislederer F, Bensler S, Specht T, et al. Plate Fixation for Irreducible Proximal Humeral Fractures in Children and Adolescents-A Single-Center Case Series of Six Patients. Children (Basel). 2021;8(8):635. doi: 10.3390/children8080635.

25. Chee Y, Agorastides I, Garg N, et al. Treatment of severely displaced proximal humeral fractures in children with elastic stable intramedullary nailing. J Pediatr Orthop B. 2006;15(1):45-50. doi: 10.1097/01202412-200601000-00010.

26. Samara E, Tschopp B, Kwiatkowski B, et al. A Single Retrograde Intramedullary Nail Technique for Treatment of Displaced Proximal Humeral Fractures in Children: Case Series and Review of the Literature. JB JS Open Access. 2021;6(1):e20.00119. doi: 10.2106/JBJS.OA.20.00119.

27. Rajan RA, Hawkins KJ, Metcalfe J, et al. Elastic stable intramedullary nailing for displaced proximal humeral fractures in older children. J Child Orthop. 2008;2(1):15-19. doi: 10.1007/s11832-007-0070-0.

28. Bahrs C, Zipplies S, Ochs BG, et al. Proximal humeral fractures in children and adolescents. J Pediatr Orthop. 2009;29(3):238-242. doi: 10.1097/BPO.0b013e31819bd9a7.

29. Haering D, Raison M, Begon M. Measurement and description of three-dimensional shoulder range of motion with degrees of freedom interactions. J Biomech Eng. 2014;136(8). doi: 10.1115/1.4027665.

30. Bourgain M, Hybois S, Thoreux P, et al. Effect of shoulder model complexity in upper-body kinematics analysis of the golf swing. J Biomech. 2018;75:154-158. doi: 10.1016/j.jbiomech.2018.04.025.