The intramedullary nailing using Rocher or Küntscher nails was applied without fracture table, because of the limited facilities.

This procedure consists of opening the site of fracture, introduction into the medullar canal of a tailored nail by retrograde way to cross the greater trochanter, reduction of the fracture, followed by gentle forward movements to push the nail of which the eyelet was left at 2-3 centimeters above the greater trochanter to permit the removal of the material after 6 to 18 months.

Evaluation consisted of clinical examination and radiography of pelvis: face incidence in dorsal position.

- Clinical examination included: measurement of the length of the lower limb and circumference of the thigh at 15 cm to the patella basis.

- Radiographic evaluation included: measurement of neck-shaft angle, the length and the width of femoral neck.

Clinical definition:

Radiographic definition:

Classification of Sequels

8 patients had minors sequels on operated members included: 6 cases of lengthening and 4 cases of atrophy of the thigh. Lengthening of the lower members and atrophy of thigh were associated in 2 cases. The lengthening of the limb were within 2-3 cm and associated with a limping.

5 patients had minor’s sequels as lengthening and thinning of femoral neck.

7 patients had majors sequels included: 4 coxa valga with lengthening and thinning of femoral neck ( figure 1), 3 coxa valga associated with shortening and thickening of femoral neck ( figure 2).

10 patients declined removal material because of reluctance to a second intervention.

8 patients have had implant removal, 4 at 16 months, 2 at 7 months, 1 at 11 months and 1 at 64 months. In these patients, the neck-shaft angle was increasingly higher than the healthy side. Among them there are 3 cases of coxa valga.

Among the 10 patients who still had their implant in place, there are 4 coxa valga. Their nail eyelet was tucked away with the bone growth or at surface level of greater trochanter ( figures 2).

The table 1 shows relationship between age of intervention and occurrence of coxa valga

The 7 patients with coxa valga were 9 years old on average with age ranged from 7 to 11 years at the time of nailing.

The 11 patients without coxa valga were 12 years old on average with age ranged from 8 to 15 years at the time of nailing.

The 7 cases of coxa valga compared to the length of the lower member were divided into 3 coxa valga out of 6 cases of lengthening of the operated member.

No patients with atrophy presented with coxa valga.

Figure 1

Pelvic radiograph showing , lengthening and thinning of femoral neck

Figure 2

Pelvic radiograph, with femoral neck shortened and squat. Rocher’s nail was hidden in the greater trochanter.

Figure 3

Relationship between age of intervention and occurrence of coxa valga

The examination of gait and measurement of the lowers members noted 6 cases of lengthening with limping. This inequality was often observed after long bone fracture, and is not results from proximal growth plate destruction. Her genesis results from vicarious lengthening due to periosteum removing during osteosynthesis. Limping was done because of the lengthening who’s become evident at 2cm. We noted, that it‘s rarely a shortening of the fractured member, but rather its lengthening. This observation was also reported by Stock⁴.

After analysis of pelvis radiographies we noted 12 abnormal femur proximal epiphysis. These anomalies might result from the destruction of growth cartilage of the greater trochanter which causes the coxa valga, whereas the lesion of the rectangular cartilage of the neck would be responsible for occurrence of thinning and the lengthening, according to Jouve et al.². Gonzalez-Herranz et al. ⁵ reported sequels as coxa valga, the stop growthing of the greater trochanter and the thinning of the femoral neck because of the destruction of the trochantero-cervical growth plate. Merki ⁶ and Stock ⁴ announced the frequency of coxa valga after femoral intramedullary nailing. Orler et al. ⁷, evoked that the femoral intramedullary nailing by antegrade way before the closure of growth plate can lead to ischemic necrosis of femoral head and a coxa-valga. In order to avoid these complications, they suggest that the nail entry point may be dorso-lateral below the trochanteric physis.

Lechevalier et al. ⁸identified 3 great complications: femoral head necrosis (3 to 5 %), coxa valga with narrowing of femoral neck and neurological complications (5 to 10%). In the same way, Templeton et al. ⁹reported that the intramedullary nailing determines a femoral head necrosis and stop the growth of the greater trochanter.

Besides Darren et al.¹⁰, about a polytraumatized adolescent evoked that apart from the damage due to the nailing, other factors like hypovolemic shock would influence the determinism of osteonecrosis of the femoral head.

Many options according to age were proposed to treat femoral fracture. Conservative treatment necessitates a long stay in hospital for traction and subsequent immobilization in cast. Among surgical methods, were described plate fixation (submuscular or open), external fixator, flexible intramedullary nails, interlocked intramedullary nails. The safeguard of the growth plates in children lead surgeon a testing of a technique of internal fixation named ‘‘stable elastic intramedullary nailing’‘ of Metaizeau¹¹. This technique uses two flexible nails which are introduced percutaneously either through the lower metaphysic or the subtrochanteric area. This technique provided adequate reduction and stabilization, with very low operative risk.

Analyze of the sequels occurring after intramedullary nailing of femur according to Küntscher, confirmed that the crossing of greater trochanter by the nail might be responsible of occurrence of coxa valga. We suggest that this technique must be avoided before 12 years old. In the case of the femur avoid the nailing as long as the growth plates of proximal epiphysis of femoral bone is not closed, particularly the growth plates of the greater trochanter.

Gordon et al.¹², Keeler et al. ¹³ with the intramedullary nailing by the antegrade with latero-trochanteric access in children did not observe any proximal deformity as coxa valga or cervical shortening or osteonecrosis.

Before 12 years old we recommend that it is necessary to make as well as possible conservative treatment or a stable elastic intramedullary nailing (ECMES), an alternative to osteosynthesis of shaft fracture or proximal femoral fracture. Indeed ECMES, a method which takes care of the integrity of the growth plates presents very low operative risk ^{14, 15}.

Coxa valga, majors sequels create an asymmetry of the pelvis, source of the hip instability, responsible of her progressive wear which leads later to coxarthrosis¹. After analyzed of this survey, we observed that coxa valga more affected the younger children under 12 years old. Gonzalez-Herranz et al.⁵ in their series frequently observed this sequel in children under 13 years old. The neck-shaft angle was higher among patients who had implant removal than others. This fact explained that the implant removal constitutes a new aggression of the growth plate which was not yet closed.

Coxa valga could be associated or not with a lengthening or atrophy of thigh on the operated member. This differentiates the genesis from vicarious lengthening due to periosteum removing during osteosynthesis, implant removal and coxa valga due to epiphysiodesis of greater trochanter’s growth plate⁸.