The clinical features, management options and complications of paediatric femoral fractures

Advantages of a Dedicated Orthopaedic Trauma Room for Children With Fractures of the Femur Treated at a Pediatric Community Hospital

Background

The benefits of a dedicated orthopaedic trauma room (DOTR) for patients with isolated femur fractures have not been reported from a pediatric community hospital.

Methods

Twenty-three years of skeletally immature patients treated for an isolated diaphyseal femur fracture with two flexible intramedullary nails, Pre-DOTR: 2000-2015 and Post-DOTR: 2016-2022, were reviewed for comparison of patient demographics and injury patterns, timing and durations of surgery, fellow presence, duration and cost of hospitalization, and complication rates.

Results

One hundred fifty-three patients were identified. One hundred twenty-six patients underwent surgery pre-DOTR and 27 post-DOTR. Demographics were similar between groups, except the post-DOTR patients were younger (mean age 7.4 years vs 9.0 years, P ​= ​0.002). There was no significant difference in the percentage of patients undergoing surgery within 18 ​h of admission pre- and post-DOTR (78% vs 93%, respectively, P ​= ​0.53). Post-DOTR surgeries were more frequently daytime (93%) than pre-DOTR (56%, P ​< ​0.001). Fellows were present in 8% of pre-DOTR vs 44% of post-DOTR procedures (P ​< ​0.0001). Average durations of surgery post-DOTR were significantly longer (118 ​min vs 93 ​min, P ​= ​0.031). Lengths of stay post-DOTR were significantly shorter (3.0 days vs 3.5 days, P ​= ​0.016), with substantial potential cost savings. There was no significant difference in complication rates pre- and post-DOTR (21% and 22%, P ​= ​0.85).

Conclusions

Implementing a guaranteed first start for orthopaedic trauma via a DOTR at a pediatric community hospital, a pediatric non-Level I or II trauma center, allowed for daytime surgery without prolonging hospital stays for pediatric patients undergoing flexible intramedullary nailing for a femur fracture. Guaranteed morning OR block time for orthopaedic trauma decreased lengths of hospital stay and enabled a larger percentage of surgeries to be done during daytime hours. Shorter hospital stays suggest substantial cost savings, while early daytime surgery for nonemergent procedures avoided burdening families with prolonged waits to surgery.

Key Concepts

(1)A daily dedicated orthopaedic trauma room (DOTR) for operative treatment of orthopaedic trauma in a pediatric community hospital results in the vast majority of femur fracture surgeries being performed during daytime hours.(2)Even with a delay of many femur fracture surgeries until the next morning, a DOTR does not increase the fraction of patients treated outside the 18-h window from admission.(3)A DOTR for operative treatment of pediatric femur fractures in a community pediatric hospital can decrease lengths of stay for patients treated for diaphyseal femur fractures.(4)A DOTR may decrease the costs of hospitalization by decreasing lengths of stay for patients treated for diaphyseal femur fractures.

Level of Evidence

Therapeutic, Level III - Retrospective comparison study.

The Double-Edged Sword: Anterior Cruciate Ligament Reconstructions on Adolescent Patients-Growth Plate Surgical Challenges and Future Considerations

The management of anterior cruciate ligament (ACL) injuries in pediatric patients presents unique challenges due to the presence of open growth plates in the proximal tibia and distal femur. Delaying ACL reconstruction until skeletal maturity may protect the physes but increases the risk of secondary injuries, such as meniscal tears and chondral damage, due to prolonged joint instability. Conversely, early surgical intervention restores knee stability but raises concerns about potential growth disturbances, including leg-length discrepancies and angular deformities. This narrative review examines current approaches to pediatric ACL management, highlighting the risks and benefits of both conservative and surgical treatments. Additionally, it explores the role of finite element modeling (FEM) as an innovative tool for pre-surgical planning. FEM offers a non-invasive method to optimize surgical techniques, minimize iatrogenic damage to growth plates, and improve patient outcomes. Despite its potential, FEM remains underutilized in clinical practice. This review underscores the need to integrate FEM into pediatric ACL care to enhance surgical precision, reduce complications, and improve long-term quality of life for young patients. By synthesizing available evidence, this review aims to provide clinicians with a comprehensive framework for decision-making and identify future directions for research in pediatric ACL reconstruction.

A Finite Element Analysis Study of Influence of Femoral Stem Material in Stress Shielding in a Model of Uncemented Total Hip Arthroplasty: Ti-6Al-4V versus Carbon Fibre-Reinforced PEEK Composite

Total hip arthroplasty is one of the most common and successful orthopaedic operations. Occasionally, periprosthetic osteolysis associated with stress shielding occurs, resulting in a reduction of bone density where the femur is not properly loaded and the formation of denser bone where stresses are confined. To enhance proximal load transfer and reduce stress shielding, approaches, including decreasing the stiffness of femoral stems, such as carbon fibre-reinforced polymer composites (CFRPCs), have been explored through novel modular prostheses. The purpose of the present study was to analyse, by the finite element analysis (FEA) method, the effect that the variation of material for the distal part of the femoral stem has on stress transmission between a modulable prosthesis and the adjacent bone. Methods: Through three-dimensional modelling and the use of commercially available FEA software Ansys R2023, the mechanical behaviour of the distal part of the femoral stem made of CFRPC or Ti-6Al-4V was obtained. A load was applied to the head of the femoral stem that simulates a complete walking cycle. Results: The results showed that the use of a material with mechanical characteristics close to the bone, like CFRPC, allowed for optimisation of the transmitted loads, promoting a better distribution of stress from the proximal to the distal part of the femur. This observation was also found in some clinical studies in literature, which reported not only an improved load transfer with the use of CFRPC but also a higher cell attachment than Ti-6Al-4V. Conclusions: The use of a material that has mechanical properties that are close to bone promotes load transfer from the proximal to the distal area. In particular, the use of CFRPC allows the material to be designed based on the patient’s actual bone characteristics. This provides a customised design with a lower risk of prosthesis loss due to stress shielding.

Outcome of early versus delayed presentation of proximal femur fractures in children: A prospective cohort study

OBJECTIVE

We hypothesized that the exact time of fixation of paediatric proximal femur fractures will have an effect on the ultimate clinical and radiological outcome. This article aimed to compare the clinical-radiological outcomes in paediatric proximal femur fractures having early and delayed presentation.

METHODOLOGY

A prospective cohort study was conducted from January 2019 to November 2022 in patients of age of 5 to 16 years presented with proximal femur fracture and divided into two groups: group A: early presentation, presented <48hours of injury; group B: delayed presentation, presented >48hours of injury. Patients underwent internal fixation treatment modality and followed up to assess clinical outcomes and radiological outcomes, and final outcome was assessed as per Ratliff's criteria.

RESULTS

In the study of 44 patients, 72.72% were male, and 27.27% were female, with male-to-female ratio to be 2.6:1. The commonest mode of injury was fall from height accounting for 52.27% followed by road traffic accidents (RTA) in 38.63%. The most common fracture type observed was Delbet type II, which was observed in 43.18%. There was significant shorter duration of surgery in group A (p-value=0.013), VAS score (p=0.045), and limb length discrepancy (p=0.022). Also, there was a statistical difference in AVN (p-value=0.0295) and growth disturbance (p-value=0.0394) between two groups. Also, there was statistically significant difference between Ratliff's criteria two groups (p-value=0.030).

CONCLUSION

Early presentation has shorter duration of surgery, less VAS score at final follow-up, and less limb length discrepancy, less development of complications like avascular necrosis of the femoral head, and growth disturbance.

LEVEL OF EVIDENCE

III.

External fixator versus elastic stable intramedullary nail for treatment of metaphyseal-diaphyseal junction fractures of the pediatric distal femur: a case-control study

BACKGROUND

Several methods have been used for the treatment of pediatric distal femoral fractures, such as elastic stable intramedullary nail (ESIN), external fixator (EF) and plate osteosynthesis, but there has been no consensus about the optimal method. The purpose of this study was to compare the clinical outcome between EF and ESIN techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal femur.

METHODS

We retrospectively analyzed operatively treated MDJ fractures of pediatric distal femur between January 2015 and January 2022. Patient charts were reviewed for demographics, injury and data of radiography. All of the patients were divided into EF and ESIN groups according to the operation techniques. Malalignment was defined as more than 5 degrees of angular deformity in either plane. Clinical outcomes were measured by Flynn scoring system.

RESULTS

Thirty-eight patients were included in this study, among which, 23 were treated with EF, and 15 with ESIN. The mean follow-up time was 18 months (12-24 months). At the final follow-up, all of the fractures were healed. Although there were no statistical differences between the two groups in demographic data, length of stay, estimated blood loss (EBL), rate of open reduction, time to fracture healing and Flynn score, the EF was superior to ESIN in operative time, fluoroscopic exposure and time to partial weight-bearing. The EF group had a significantly higher rate of skin irritation, while the ESIN had a significantly higher rate of malalignment.

CONCLUSION

EF and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal femur. ESIN is associated with lower rates of skin irritation. However, EF technique has the advantages of shorter operative time, reduced fluoroscopic exposure, and shorter time to partial weight-bearing, as well as lower incidence of malalignment.

LEVEL OF EVIDENCE

Level III.

Treatment of Delbet II/III Pediatric Femoral Neck Fractures With Proximal Femoral Locking Plate Versus Cannulated Screws

INTRODUCTION

Complications following operative treatment of pediatric femoral neck fractures include nonunion, coxa vara, and avascular necrosis (AVN). Proximal femoral locking plates (PFLPs) provide a fixed-angle construct that may reduce the rates of coxa vara, but their use in pediatric femoral neck fractures has not been studied. The purpose of this study was to evaluate rates of union, coxa vara, and AVN in traumatic pediatric femoral neck fractures treated with PFLP or cannulated screws (CS).

METHODS

We retrospectively reviewed all traumatic, nonpathologic Delbet II/III femoral neck fractures in patients below 18 years of age treated with PFLP or CS. All cases had ≥6 months of radiographic follow-up to evaluate for osseous union and AVN. Changes in proximal femoral alignment were determined by measuring injured and contralateral femoral neck-shaft angle and articulotrochanteric distance (ATD) between 6 and 12 months postoperatively.

RESULTS

Forty-two patients were identified with mean age at surgery of 10.7±2.9 years (range 3.3 to 16.3 years) and mean follow-up of 36±27 months. Sixteen patients (38%) underwent PFLP fixation, whereas 26 patients (62%) underwent CS fixation. When compared with the CS cohort, the PFLP cohort had a greater proportion of males (87.5% vs. 50%, P =0.02) and Delbet III fractures (68.8% vs. 15.4%, P <0.001). There was no difference between PFLP and CS cohorts with respect to rates of union (81% vs. 88%, respectively, P =0.66), AVN (25% vs. 35%, respectively, P =0.73), or secondary surgery (62% vs 62%, P =0.95). There was no significant difference in neck-shaft angle between injured and contralateral hips in those patients treated with PFLP ( P =0.93) or CS ( P =0.16). However, the ATD was significantly decreased in hips treated with CS compared with the contralateral hip (18.4±4.6 vs. 23.3±4.2 mm, P =0.001), with no significant difference in the PFLP group ( P =0.57).

CONCLUSIONS

This study suggests that the use of a PFLP in Delbet II/III femoral neck fractures does not appear to significantly increase nonunion rates or AVN and maintains anatomic ATD when compared with screw fixation.

LEVEL OF EVIDENCE

Level III-therapeutic study.

Traumatic injuries of the immature hip and pelvis

PURPOSE OF REVIEW

The pelvis and hip account for 0.3--4% of fractures of the immature skeleton, and generally result from high energy trauma. These fractures range in severity from apophyseal avulsions to complete disruptions of the pelvic ring. The purpose of this article is to review the presentation, diagnosis, treatment and complications of these injuries in order to inform clinicians involved in their management. There is a lack of evidence-based management protocols for fractures of the immature pelvis largely due to their rarity and lack of robust scientific literature on the topic.

RECENT FINDINGS

Computed tomography/MRI is essential as up to 30% of pelvis and 70% of acetabular fractures are not identified on initial radiographs. A sub-optimal outcome is common in unstable fractures treated conservatively and adequate reduction and surgical stabilization is often required to avoid long-term morbidity.

SUMMARY

A coordinated approach involves resuscitation and temporary stabilization with planned definitive fixation. It is generally accepted that these injures should be managed in paediatric trauma centres. Whilst injuries vary in pattern and severity, we present an overview that considers the evaluation and treatment of the paediatric patient with pelvic and hip fractures to ensure that these injuries are identified promptly and treated by surgeons familiar with contemporary management algorithms.

K-Wire-Based External Fixator for Management of Salter-Harris Type-II Distal Femur Physeal Injury

We present a case of a 16-year-old male with a Salter-Harris type II physeal slip of the distal femur managed with closed reduction and K wire and clamp-based external fixator. Knee range of motion exercises were initiated after one week. The union was observed at 10 weeks, and implant removal was done on an outpatient basis. At one year follow-up, the patient had good clinical and radiological outcomes. The K-wire-based external fixator frame is an effective fixation method for distal femur physeal slips in older children, providing favorable radiological and functional outcomes.

A Rare Case of Salter-Harris Type I Growth Plate Injury in a Patient Undergoing Limb-Lengthening Procedure

Growth plate injuries over the distal femur typically occur due to high-energy trauma. It is commonly associated with serious complications such as growth disturbance. Its occurrence in children undergoing limb-lengthening procedures is uncommon. We report a case of distal femur growth plate injury in a 13-year-old boy undergoing a limb-lengthening procedure for femoral hypoplasia. Conservative treatment yielded a good functional outcome in this patient.

Bone wax in the treatment of partial epiphysiodesis of distal femoral growth plate: Case report at 10-year follow-up

The growth plate is the weakest structure in the skeleton of a child and a frequent site of injury or fracture; physeal injuries represent 15%-30% of all fractures in children. Of all growth plate fractures, the incidence of growth arrest and disorders is around 15%. Here, we discuss a female patient who, at the age of 5 years, was treated for a polytrauma that involved a complex lesion of the growth plates of the knee. Four days after trauma, she underwent closed reduction surgery and internal fixation with cannulated screws for femoral and tibial fractures of the growth plate. A 20° valgus deviation of the left knee was found at 3-month postoperative clinical check-up likely as a result of a growth disorder of the femur. She was diagnosed with valgus knee secondary to epiphysiodesis of the lateral portion of the femoral physis and she was readmitted to the hospital. In the operating theater, an open femoral de-epiphysiodesis was performed with a burr; the drilled hole was then filled with bone wax. At 20-month post-trauma follow-up, the left knee was still valgus about 20° relative to the other side. During follow-up, a slow but progressive improvement in the axis of the lower limbs was noted. Clinical and radiographic control 10 years after the trauma showed a complete recovery of the axis of the lower limbs. In the initial stages, the presence of bone wax in the area of de-epiphysiodesis allowed for stabilization of the deformity on the 20° of preoperative valgus. The interpretation of the growth cartilage activity occurred in an asymmetrical way such as to realign the femoral load axis, it can be based on the different mechanical stimulus on the two knee areas due to the preexisting deformity. There is no unanimous evidence in the literature in terms of management of growth disorders resulting from this type of injury. Bone wax resulted in effectively filling the hole of de-epiphysiodesis in the distal femoral growth plate and allowed us to obtain the response of the growth plate and to improve the recovery time in young children.

Distal femoral fractures in children

The physis of the distal femur contributes to 70% of femoral growth and 37% of the total limb growth; therefore, physeal injury can lead to important alterations of axes and length. Distal metaphyseal corner-type fracture prior to walking is classically associated with child abuse. In children aged >10 years, sports-related fractures and car accidents are significant contributors. Imaging includes a two-plane radiographic study of the knee. It is recommended to obtain radiographs that include the entire femur to rule out concomitant injuries. In cases of high suspicion of distal metaphyseal fractures and no radiographic evidence, CT or MRI can show the existence of hidden fractures. Fractures with physeal involvement are conventionally classified according to the Salter-Harris classification, but the Peterson classification is also recommended as it includes special subgroups. Conservative and surgical management are valid alternatives for the treatment of these fractures. Choosing between both alternatives depends on factors related to the fracture type. As there is a high risk of permanent physeal damage, long-term follow-up is essential until skeletal maturity is complete.