Flexible intramedullary nailing for distal femoral fractures in patients with myopathies

Emergencies cards for neuromuscular disorders 1st Consensus Meeting from UILDM - Italian Muscular Dystrophy Association Workshop report

Acute hospitalisation may be required to support patients with Neuromuscular disorders (NMDs) mainly experiencing respiratory complications, swallowing difficulties, heart failure, urgent surgical procedures. As NMDs may need specific treatments, they should be ideally managed in specialized hospitals. Nevertheless, if urgent treatment is required, patients with NMD should be managed at the closest hospital site, which may not be a specialized centre where local emergency physicians have the adequate experience to manage these patients. Although NMDs are a group of conditions that can differ in terms of disease onset, progression, severity and involvement of other systems, many recommendations are transversal and apply to the most frequent NMDs. Emergency Cards (EC), which report the most common recommendations on respiratory and cardiac issues and provide indications for drugs/treatments to be used with caution, are actively used in some countries by patients with NMDs. In Italy, there is no consensus on the use of any EC, and a minority of patients adopt it regularly in case of emergency. In April 2022, 50 participants from different centres in Italy met in Milan, Italy, to agree on a minimum set of recommendations for urgent care management which can be extended to the vast majority of NMDs. The aim of the workshop was to agree on the most relevant information and recommendations regarding the main topics related to emergency care of patients with NMD in order to produce specific ECs for the 13 most frequent NMDs.

Flexible intramedullary nailing for supracondylar femoral fractures in children with Duchenne muscular dystrophy

Case series

Patients: 11-year-old • 12-year-old

Final Diagnosis: Duchenne muscular dystrophy

Symptoms: Fracture

Medication: —

Clinical Procedure: —

Specialty: Orthopedics and Traumatology

Flexible Femoral Nailing of an Awake Adult Muscular Dystrophy Patient

Femoral fractures can be common in nonambulatory patients with myopathies because they present with notable osteoporosis. From the orthopaedic perspective, this can be complicated by a pre-existing knee flexion contracture and small femoral shaft size. The goals of treatment are to reduce external immobilization, maximize comfort for transfers, prevent functional loss, and preclude refracture. The purpose of our work is to describe the anesthetic and orthopaedic considerations in treating a bed-bound adult patient with nemaline dystrophy and a midshaft femur fracture. The authors have obtained the patient's informed written consent for print and electronic publication of the case report.

Flexible intramedullary nailing in the treatment of forearm fractures in children and adolescents, a systematic review

Background

Forearm fractures are common injuries among children and adolescents. Traditionally, they were managed conservatively with closed reduction and cast immobilization. The last decade there is an increasing trend towards operative treatment. The treatment modalities available include plate and screws, flexible intramedullary nailing and external fixation devices - rarely used nowadays. The aim of this systematic review is to investigate the indications of flexible intramedullary nailing in the childhood population, to compare its results with plating and to provide detailed information considering technical pitfalls and complications that may be encountered.

Materials and methods

An extensive search was performed in the electronic databases (PubMed, EMBASE) from their inception up to June 2019 in order articles relevant to this review to be retrieved. The search terms used were the following: forearm fracture, both-bone fracture, pediatric, nailing, fixation. 56 articles were considered suitable for inclusion.

Results

The indications for surgery are unstable and irreducible fractures, open and fractures with neurovascular compromise. As far as the fracture site is concerned, radius and ulna shaft fractures, radial head and Monteggia fractures are suitable for nailing.Although plates and nailing have comparable clinical outcomes and complication rates, flexible intramedullary nailing has the advantage of smaller incisions, less tissue disruption, shorter operative and hospital times and an ease in hardware removal.Controversy exists over the need of single or double nailing in both-bone fractures of the forearm. In addition, there is no consensus as to which is the preferred nail diameter. Yet, all the authors agree that open reduction must be considered after certain failed closed reductions in order compartment syndrome to be avoided.Flexible intramedullary nailing is not complication-free. Skin irritation, Extensor Pollicis Longus rupture, superficial radial nerve injury, delayed union or even nonunion, malunion and refractures are some of the complications that may be encountered.

Discussion

Flexible nails are excellent implants combining stability and elasticity. The procedure of passing the nails across radius and ulna is relatively simple, requiring a small learning curve. Flexible intramedullary nailing is an excellent treatment modality for the treatment of forearm fractures in children and adolescents.

Orthopedic and Surgical Management of the Patient With Duchenne Muscular Dystrophy

Orthopedic care is an important aspect of the overall management of patients with Duchenne muscular dystrophy (DMD). In addition to progressive muscle weakness and loss of function, patients may develop joint contractures, scoliosis, and osteoporosis, causing fractures; all of these necessitate intervention by a multidisciplinary team including an orthopedic surgeon as well as rehabilitation specialists such as physio- and occupational therapists. The causes of these musculoskeletal complications are multifactorial and are related to primary effects on the muscles from the disease itself, secondary effects from weak muscles, and the related side effects of treatments, such as glucocorticoid use that affect bone strength. The musculoskeletal manifestations of DMD change over time as the disease progresses, and therefore, musculoskeletal management needs change throughout the life span of an individual with DMD. In this review, we target pediatricians, neurologists, orthopedic surgeons, rehabilitation physicians, anesthesiologists, and other individuals involved in the management of patients with DMD by providing specific recommendations to guide clinical practice related to orthopedic issues and surgical management in this setting.

Diagnosis and management of Duchenne muscular dystrophy, part 2: respiratory, cardiac, bone health, and orthopaedic management

A coordinated, multidisciplinary approach to care is essential for optimum management of the primary manifestations and secondary complications of Duchenne muscular dystrophy (DMD). Contemporary care has been shaped by the availability of more sensitive diagnostic techniques and the earlier use of therapeutic interventions, which have the potential to improve patients' duration and quality of life. In part 2 of this update of the DMD care considerations, we present the latest recommendations for respiratory, cardiac, bone health and osteoporosis, and orthopaedic and surgical management for boys and men with DMD. Additionally, we provide guidance on cardiac management for female carriers of a disease-causing mutation. The new care considerations acknowledge the effects of long-term glucocorticoid use on the natural history of DMD, and the need for care guidance across the lifespan as patients live longer. The management of DMD looks set to change substantially as new genetic and molecular therapies become available.

A meta-analysis of flexible intramedullary nailing versus external fixation for pediatric femoral shaft fractures

To compare the difference in efficacy following flexible intramedullary nailing (FIN) and external fixation (EF) for pediatric femoral shaft fractures. A systematic search was performed on PubMed, Embase, Medline, and Cochrane library for relevant studies. We included controlled trials comparing complications between FIN and EF for pediatric femoral shaft fractures published before 25 November 2014. Modified Jadad scores were utilized to assess the methodological quality of the studies included. The meta-analysis was carried out using Stata 12.0 software. Six studies involving 237 patients were included. On comparison of EF, a low incidence of overall complications [relative risk (RR)=0.30, 95% confidence interval (CI): 0.19-0.46; P<0.001] and pin-tract infection (RR=0.286, 95% CI: 0.13-0.61; P=0.001), but a high risk of soft tissue irritation (RR=1.86, 95% CI: 1.35-2.56; P<0.001) were found in patients treated with the FIN approach. No significant differences in other complications were found. On the basis of current evidence, the use of FIN leads to fewer complications than EF and may be considered as the first-line approach in the treatment of femoral shaft fractures.

The Targon PH(®) nail for distal femoral fracture fixation in disabled children. A report of three cases

Recommendations for distal femoral fracture treatment in children with neuromuscular disease are various, including conservative, plating, nailing, and ESIN. All methods have disadvantages. Retrograde femoral intramedullary nailing using a statically interlocked Targon PH nail was performed in three cases. A right nail was used for a right femur (and vice versa). A short nail was used for supracondylar fractures, a long nail for distal femoral shaft fractures. Closed reduction was performed in all cases. Despite osteopenia, small bone dimensions and muscle dystrophy, no intraoperative or postoperative complications occurred. All cases achieved primary stability, allowing immediate rehabilitation. Bone healing occurred uneventfully within four months. No deterioration of functional status or range of motion was seen. There were no peri-implant fractures or hardware removal need over a two-year-period. Retrograde femoral nailing with the Targon PH nail seems to be a reasonable treatment concept for these rare and demanding cases.

LEVEL OF EVIDENCE

IV.

[Current care strategies for Duchenne muscular dystrophy]

BACKGROUND

The medical care of patients with Duchenne muscular dystrophy (DMD) is an interdisciplinary and multifaceted task. The vast majority of those affected show a nearly constant course which is reflected in a corresponding stage-oriented treatment concept. Although there is still no causal therapy available for DMD, the course and in particular the quality of life of patients can be decisively improved by established medical practices.

THERAPEUTIC STRATEGIES

The orthopedic problems of DMD patients include contractures of the upper and lower extremities as well as sitting instability due to progressive scoliosis with pelvic imbalance. The orthopedic treatment incorporates conservative measures, such as physiotherapy, provision of orthotic devices and wheelchairs as well as surgery to resolve contractures of the lower extremities and surgical stabilization of the spine. Furthermore, in these patients orthopedic surgeons and trauma surgeons are confronted with the treatment and prophylaxis of fractures induced by osteoporosis. An early onset of glucocorticoid therapy markedly delays the loss of motor abilities.

TREATMENT ASPECTS

An important aspect in the care of DMD patients is the timely prophylaxis and treatment of respiratory insufficiency with regular sessions of breathing therapy, learning breathing and coughing techniques and the sufficiently early start of non-invasive mechanically assisted ventilation. Of similar relevance are also the early recognition and cardioprotective treatment of cardiomyopathy.

CONCLUSION

The orthopedic surgeon accompanies the patient and family through all stages of the disease and must be appropriately informed on current management and treatment strategies even outside the limits of the personal field of specialization.