External fixation for closed pediatric femoral shaft fractures: where are we now?

Mechanical evaluation of the effect of the rod to rod distance on the stiffness of uniplanar external fixator frames

PURPOSE

To investigate the effect of the rod-to-rod distance on the mechanical stability of single-rod and double-rod external fixator frames.

METHODS

 Four different constructs, one single-rod and three double-rod constructs with different rod-rod distances, were subjected to the axial, bending, and torsional forces. The stiffness of different configurations was calculated.

RESULTS

 Single-rod configuration had statistically the lowest stiffness when subjected to the axial, bending, and torsional forces. Maximum stiffness against the axial and anterior-posterior bending forces was achieved when the rod-rod distance was adjusted to 50 mm (halfway between the first rod and the end of the Schanz pins). There was no statistically significant difference in lateral bending stiffness among different double-rod configurations (p value: 0.435). The maximum stiffness against torsional forces was achieved when the rod-rod distance was adjusted to 100 mm (the second rod at the end of the Schanz pins).

CONCLUSION

 Double-rod uniplanar external fixator frames are significantly stiffer than the single-rod constructs, and however, the rod-rod distance can significantly affect the construct stiffness. We found that a frame with 50 mm rod-rod distance was the optimum fixator among tested configurations that allowed a balance between axial, bending, and torsional stiffness of the construct.

Can Rigid Femoral Nailing Be Used for Pediatric Femoral Shaft Fracture in Children 8 to 10 Years? Use of RIN in Patients With Femoral Shaft Fracture

BACKGROUND

The treatment modalities for pediatric femoral shaft fractures are determined by their age, weight, and fracture pattern. Rigid intramedullary nailing (RIN) is usually recommended for patients >11 years of age, and elastic intramedullary nailing (EIN) has been used for patients under 10 years. However, little is known about the use of RIN in patients aged 8 to 10 years. We examined the differences in patients with femoral shaft fractures who were treated with EIN or RIN in terms of (1) fracture healing; (2) changes of anatomic parameters; and (3) related complications.

METHODS

We retrospectively reviewed 54 patients between 8 and 10 years of age, with femoral shaft fractures, who were treated with either EIN or RIN between 2011 and 2020. Lateral trochanteric entry was used for RIN procedure. The mean follow-up period was 26.4 months (range, 6 to 113 mo). There were 17 patients in the EIN group and 37 patients in the RIN group. The mean age at the time of surgery was 1 year younger in the EIN group ( P <0.01). The mean weight of the patient was significantly heavier in the RIN group compared with the EIN group.

RESULTS

Complete union of the fracture was achieved slightly faster in the RIN group at 3.4 months compared with 3.7 months in the EIN group ( P =0.04). There were no clinically significant changes of the anatomic parameters in either group, including neck shaft angle and articulotrochanteric distance. There was no evidence of avascular necrosis at the time of final follow-up for either group. There were no significant differences in postoperative complications between the groups.

CONCLUSION

RIN using lateral trochanteric entry is a feasible surgical option for femoral shaft fractures in patients 8 to 10 years of age that are heavier than 40 kg or with unstable fracture patterns.

LEVEL OF EVIDENCE

Level III, retrospective cohort study. See the Guidelines for Authors for a complete description of levels of evidence.

Resource implications of managing paediatric femoral fractures in a major trauma centre: Analysis of 98 cases

INTRODUCTION

The management of paediatric femoral shaft fractures is expensive and is guided by age and fracture characteristics. The primary aim of this study was to perform a cost evaluation for managing paediatric femoral shaft fractures. The secondary aim of this study was to perform and compare costs of the different techniques of managing paediatric femoral shaft fractures.

METHODS

Ninety-eight femoral shaft fractures in children aged ≤16 were identified between 01/06/2014-30/06/2019. Retrospective data of clinical complications were obtained on infection, malunion and non-union. Data on additional intervention, reoperations for complications and routine removal of metal work were obtained. Costing analysis was performed by a bottom-up calculation, and gathering Patient Level Information and Costing System (PLICS) data.

RESULTS

There were 41 hip spica casting (HSC), 21 flexible intramedullary nailing (FIN), 14 submuscular plating (SMP), 19 rigid intramedullary nailing (RIN) and 3 external fixation (EF). Complications observed were HSC 3(7%); FIN 8(38%); SMP 2(14%); RIN 1(5%); EF 2(67%). The total costs for managing femoral shaft fractures were £8,955pp the costs for the different managements were; HSC £3,442pp; FIN £7,739pp; SMP £6,953pp; RIN £8,925pp; EF £19,116pp. The additional costs incurred for managing complications and routine removal of metal work for the internal fixation methods were: HSC 0.7%, FIN 23.7%, SMP 16.3%, RIN 10.9%, EF 28.1%.

CONCLUSION

The operative management of paediatric femoral shaft fractures is associated with a high cost burden and this study demonstrates how financial data can be used to influence clinical management strategy. RIN carry a high initial implant cost however when considering the additional costs, such as treating complications it remains comparable to other modes of fixation. Our cost analysis did not demonstrate a significant difference between FIN, SMP and RIN. Due to the clinical complications observed and associated additional costs, we have discontinued the routine use of FIN for femoral shaft fractures at our centre. We recognise other centres may have a different complication and cost profile for each technique, but recommend they evaluate their practice given the potential economic benefit it has on the service provider.

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.

Single stage open reduction, intramedullary rod, bone grafting, and plate fixation for managing adolescent midshaft femoral fracture non-union, report of two cases

Although rare, long bones fracture non-union in pediatric and adolescent patients is still being reported. It poses a challenge for the trauma surgeons, although principles for adult patient management apply to pediatrics and adolescents; however, there is no standard protocol to deal with such situations. We report two male adolescent patients, 11 and 12 years old, presented with non-united midshaft femoral fracture non-union after being multiply operated on. One patient was diagnosed with a septic non-union, while the other had an atrophic type. Both were treated following the same technique of open surgery where debridement and refreshing of the fracture site were performed, followed by initial fixation using an intramedullary rod, the biological environment was then enhanced by the addition of autologous iliac bone graft, and the fixation was finalized using a 4.5 dynamic compression plate. Both patients achieved complete fracture union and excellent functional outcomes by the last follow up. Adolescent patients presented with multiply operated non-united femoral fracture could be successfully treated using the described technique. It improves the mechanical and biological environment with the advantage of being a single-stage surgery.

The Bisaccia and Meccariello technique in pediatric femoral shaft fractures with intramedullary titanium nail osteosynthesis linked external-fixator (IOLE): validity and reliability

Background:

Over the last 20 years, the incidence of pediatric femoral shaft fractures was increased, due to changes in the children’s daily activities. The healing times are different according to the chosen treatment and to other factors such as age, type of fracture, the involvement of the soft tissues, and concomitance with other injuries. The Bisaccia and Meccariello technique (Intramedullary titanium nail Osteosynthesis Linked External-fixator -IOLE) was born to prevent rotationally and lengthening malunion or nonunion in the treatment of pediatric femoral shaft fractures.

Hypotheis:

The aim or the objective of this paper is to compare the IOLE with the two most used methods for the treatment of femoral fractures in children.

Methods:

From 2000 to 2016, 58 pediatric patients with femoral shaft fractures were surgically treated and enrolled in the study. The ranged age of the patients was between 3 and 15 years. Twenty-two patients were treated with endomedullary titanium nails (TEN), 22 with external axial or modular external fixators and 14 patients treated with IOLE technique. The IOLE technique, in brief, is the hybridization of titanium intramedullary nails with a modular external fixator. It is divided into three phases, the first revenue given the length of the femur with the external fixator; the second, the rotations are dominated by the elastic nails; and the third finally they are hybridized on the external fixator. Comparing the three groups, radiographic images were taken to assess fracture reduction and consolidation.

Results:

At the final follow-up, statistically significant differences in not weight-bearing times were found in favor of the IOLE group. There were no statistical differences between three groups in terms of significant rotation defects, angulation, growth, and/or nonunion.

Conclusions:

The Bisaccia- Meccariello technique (IOLE) showed to lead to healing the pediatric femoral shaft fracture of the femur but allows an early weight-bearing to these patients and normal life like that.

Role of mini-invasive bridge plate in the complex femoral fracture in school going children: A prospective clinical study of 30 cases

Objective:

Pediatric femoral fracture including supracondylar and subtrochanteric fracture constitutes 1.6% of all paediatric fracture. Elastic nails remain the standard treatment of choice in a midshaft transverse femoral fracture in children weighing less than 45 kg. But in subtrochanteric and spiral femoral fracture, the failure rate of elastic nails are quite high. Hence, in accordance with AAOS guidelines, we treated complex femoral fracture in children with submuscular mini-invasive bridge plate because of its advantage of minimal incision, early union with proper alignment and lower failure.

Material and Methods:

We retrospectively reviewed 30 complex femur fracture in children treated with Submuscular bridge plate by mini-invasive approach. Patients were analysed according to their age, type of fracture, time of union in weeks, complication and results were evaluated with modified Flynn's criteria.

Result:

Out of 30 patients 28 were boys and 2 were females, with an average age of 11.5 years in which Spiral fracture (n = 12), subtrochanteric fracture (n = 9), Complex Shaft fracture (n = 10). All fracture united well on an average of 11 weeks. And 29 patients has excellent results and in 1 patient there is Acceptable result. The single complication was 3 mm limb lengthening but it didn't change gait of the patient.

Conclusion:

Mini invasive bridge plating is an easy and soft tissue preserving procedure for managing complex femoral fracture in children. It has shown promising results in achieving union without any major complication. We strongly recommend the SBP in a complex femoral fracture in children.

Risk factors for refracture of the femoral shaft in children after removal of external fixation

Background

External fixation is the primary treatment option in children for femoral shaft fractures, such as open femoral or multiple fractures. One complication is refracture, which is the biggest limitation of fixation devices. This study aims to investigate the risk factors associated with refracture after the removal of external fixation devices and decrease the frequency of refracture.

Materials and methods

Retrospectively reviewed clinical data of 165 patients treated at our hospital for fresh femoral shaft fractures with external fixation between May 2009 and February 2018 were included in this study. Patients with pathological fractures, fractures of the femoral neck, fractures that were fixed using plates or elastic stable intramedullary nailing, and old fractures, as well as those who underwent postoperative femoral surgery were excluded. Potential risk factors included: patient age, gender, and weight, fracture sides, open or closed fracture, fracture sites, reduction methods, operation time, perioperative bleeding, number and diameter of the screws, and immobilization time. These factors were identified by univariate and logistic regression analyses.

Results

Femoral shaft refracture developed in 24 patients. Univariate analysis revealed that refracture was not statistically significantly associated with any of the above factors, except AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) classification type 32-D/4.2 and L2/L3 ratio (L2, length of femur fixed by the two screws farthest from the fracture line; L3, the total length from the greater trochanter to the distal end of femur; P < 0.001 and P = 0.0141, respectively). Multivariate analysis showed that PCCF classification type 32-D/4.2 and L2/L3 ratio were also independent risk factors for femoral refracture.

Conclusions

Femoral shaft refracture is relatively common in children treated with external fixation. Because of the limited number of cases in this study, we cautiously concluded that the PCCF classification type 32-D/4.2 and L2/L3 ratio were independent risk factors for femoral shaft refracture in these patients.

Level of evidence

IV

[Diaphyseal and metaphyseal femoral fractures in childhood]

Femoral fractures in childhood are rare and are usually the result of severe trauma. Conservative treatment (overhead extension, hip spica cast) can be used in children up to 3 years of age and beyond that elastic stable intramedullary nailing (ESIN) is the method of choice. The prognosis is very good if the surgical technique is adequate. In adolescents > 50 kg in body weight solid nails implanted via the greater trochanter are an alternative (adolescent lateral femoral nail, ALFN). External fixators and plate osteosynthesis are indicated in special situations. Femoral neck fractures are very seldom seen in this age group. Besides Kirschner (K)-wires and screw osteosynthesis a special pediatric hip plate is available in this situation. In the distal metaphysis mostly stable fractures occur in disabled children, which can usually be treated conservatively. In addition, pathological fractures occur in juvenile bone cysts and complex injuries in adolescents, which need stabilization by descending ESIN or with plates. At the distal growth plate relevant growth disturbances are possible.

Operative Choice for Length-Unstable Femoral Shaft Fracture in School-Aged Children: Locking Plate vs. Monolateral External Fixator

BACKGROUND

Locking plate (LP) is a good choice in the treatment of length-unstable femoral shaft fracture in children. Monolateral external fixator (EF) has been reported for this condition for decades. This study aims to compare the clinical outcomes of school-aged children with length-unstable femoral shaft fracture treated with LP vs. EF.

METHODS

Patients aged 5-11 years old with length-unstable femoral shaft fractures treated at our institute from January 2014 to January 2018 were retrospectively reviewed and categorized into LP and EF groups. The preoperative data, including baseline information of the patients, radiographic parameters, and types of surgical procedure, were collected from the hospital database, and postoperative data, including complications, were collected during the follow-up visits.

RESULTS

Overall, 36 patients (average, 8.2 ± 2.1 years; male, 20; female, 16) in the LP group and 35 patients (average, 8.3 ± 2.3 years; male 20, female 15) in the EF group were included. There was significantly less operative time for EF (45.4 ± 7.8 min) compared with LP (67.8 ± 11.3 min) (P < 0.001). As for the frequency of fluoroscopy, there was a significant difference between the EF (13.9 ± 2.4) and LP (16.5 ± 3.2) groups (p < 0.001). The rate of major complications was not significantly different between these two groups. There was a significant difference between the EF group (11.2 ± 5.8 mm) and the LP group (7.5 ± 1.6 mm) group concerning limb length discrepancy (P < 0.001).

CONCLUSION

Both LP and EF produce satisfactory outcomes in school-aged children with length unstable femoral shaft fractures. External fixation remains a viable choice without the necessity of secondary surgery for hardware removal.

Presentation and outcome of femoral infected non-unions in children and adolescents

Objectives

To document the presentation of infected non-unions of femur in pediatric and adolescent population and evaluate the outcome of segmental bone transport with the Ilizarov method.

Methods

This prospective case series study was carried out over a period of five years, from January 01, 2015 to December 31, 2019. The study included all children and adolescent patients who presented with femoral infected non unions. The study excluded patients above the age of 16 years and those who had pathological fractures secondary to bone pathologies such as cysts, tumors or metabolic bone diseases.

Results

Out of 31 patients, 27(87.09%) were males and 4(12.90%) were females. The mean age was 13.48±1.98 years. The underlying mechanisms that lead to the causation of fractures included road traffic accidents (n=23;74.19%), fall from height (n=7;22.58%) and firearm injuries (n=1;3.22%). The bone gaps ranged from 3-5 cm with a mean of 4.00± 0.856 cm. Bone union was achieved among 28(90.32%) patients. Infection was eradicated among 27(87.09%) patients whereas the remaining patients continued to suffer persistent infection. The most common complications included pin tract inflammation/ infection among (n=31;100%) patients and stiffness of knee joint among (n=19;61.29%) patients.

Conclusion

Majority of the patients were males, aged 9-16 years. Road traffic accidents were the commonest cause of the fractures. The Ilizarov method of segmental bone transport was effective in treating the majority of infected non-unions.

Pediatric Femoral Shaft Fracture: An Age-Based Treatment Algorithm

PURPOSE

Fractures of the femoral shaft in children are common. The rates of bone growth and remodeling in children vary according to their ages, which affect their respective management.

METHODS

This paper evaluates the incidence and patterns of pediatric femoral shaft fracture and the current concepts of treatments available.

RESULTS

The type of fracture-closed or open; stable or unstable-needs to be taken into account. Child abuse should be suspected in fractures sustained by infants. For younger children, non-surgical management is preferred, which include Pavlik harness (< 6 months old) and early spica casting (6 months to 6 years old). Older children (> 6 years old) usually benefit from surgical treatments as outcomes of non-surgical alternatives are worse and are associated with prolonged recovery times. These operative measures for older children that are 6-12 years old include elastic stable intramedullary nailing and submuscular plating. Factors to be considered when devising an appropriate intervention include body mass, location of injury, and nature of fracture. For adolescent and skeletally mature teenagers (> 12 years old), rigid antegrade entry intramedullary fixation is indicated. In the event of open fractures or polytrauma, external fixation should be considered as a temporary treatment method for initial fracture stabilization.

CONCLUSION

An age-based and evidence-based algorithm has been proposed to guide surgeons in the process of evaluating an appropriate treatment.

Osteosynthesis of pediatric femoral shaft fractures with flexible intramedullary nailing-experience from developing world

BACKGROUND

Flexible intramedullary nailing (FIN) has become the standard treatment for pediatric femoral fractures in the 6-14 years age group. The other treatment options include traction plus spica casting and external fixation. In spite of excellent results described, there is disunity in the orthopedic fraternity regarding its usefulness and nail material. The aim of our study is to determine the outcome of pediatric femur fractures treated with Stainless steel FIN.

METHODOLOGY

Between 2014 to 2018, 45 children within the age group of 6-12 years with femoral shaft fractures were included in the study. Two Stainless steel nails of predetermined size were inserted in a retrograde fashion under fluoroscopy. Patients were followed up at regular intervals to assess clinical and radiological parameters. Final results were evaluated using Flynn's clinical criteria.

RESULTS

There were 29 boys and 16 girls with an average age of 10.2 years. Fracture patterns included transverse (n=8), oblique (n=20), spiral (n=12) and comminuted (n=5). Open injuries were present in two cases and five patients had associated injuries. The mean injury to surgery interval was 2.9 days, mean hospital stay was 4.8 days and mean time to union was nine weeks. Complications included deep infection with delayed union in one case, superficial infection in two cases, malunion in three cases, limb length discrepancy of >10 mm in one patient and skin irritation from prominent nail tips in five patients. Results were excellent in 36 patients, satisfactory in eight patients and poor in one patient.

CONCLUSION

FIN is safe, reliable and efficacious method of fixation because of its simplicity, minimal invasiveness, ease of insertion and removal with better cosmesis, rapid union with short rehabilitation, less psychosocial stress to the patient and family.

Titanium Elastic Nails Are a Safe and Effective Treatment for Length Unstable Pediatric Femur Fractures

BACKGROUND

Controversy exists regarding the treatment of length unstable pediatric femoral shaft fractures. The purpose of this study was to investigate the outcomes of skeletally immature children with length unstable femur fractures treated with titanium elastic nails (TENs).

METHODS

A retrospective review was conducted on all patients with femoral shaft fractures at a tertiary care pediatric hospital from April 2006 to January 2018. Patients with femoral shaft fractures treated with TEN and minimum 6 months follow-up were included. Exclusion criteria were age 11 years or above, weight >50 kg, pathologic fracture, and neuromuscular disorders. Femur fractures were categorized into 2 groups: length unstable (spiral, comminuted, or long oblique fractures) versus length stable (transverse and short oblique). Complications and reoperations were compared between the groups.

RESULTS

A total of 57 patients with 58 femoral shaft fractures were included. The mean age was 5±2 (1 to 11) years and mean follow-up was 20.4±18.1 (6.0 to 81.2) months. The mean weight was 22.9±7.7 (11.0 to 40.5) kg. There was no difference in age (P=0.32), weight (P=0.28) or follow-up length (P=0.57) between patients with length unstable fractures and those with length stable fractures. A total of 32/58 (55%) fractures were length unstable and 26/58 (45%) were length stable. Mean time to union was 4.6 months, and there was no significant difference in mean time to union between the 2 groups (P=0.71). Thirty-one complications occurred in 27 patients. There was no difference between groups in the incidence of major complications requiring revision surgery (P=0.68) and minor complications that did not require revision surgery (P>0.99).

CONCLUSIONS

In children with femoral shaft fractures treated with TEN, there was no difference in the incidence of complications or reoperations between those with length unstable fractures and those with length stable fractures. TEN are a safe and effective choice for operative fixation of length unstable femoral shaft fractures in children.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Distal third femoral shaft fractures in school-aged children: A comparative study of elastic stable intramedullary nail and external fixator

Internal fixation such as elastic stable intramedullary(ESIN) nail and submuscular plate (SMP) is gaining popularity for femoral shaft fractures in school-aged children. However, external fixation (ExFix) might be a valuable option for the distal third femoral shaft fractures, where the fracture heals rapidly, but it is crucial to avoid angular malunion. This study aims to compare the clinical outcomes, postoperative complications of distal third femoral shaft fractures in school-aged children treated by ESIN versus ExFix.Patients aged 5 to 11 years with distal third femoral shaft fractures treated at our institute from January 2014 to January 2016 were included and categorized into ESIN (n = 33) and ExFix (n = 38) group. The preoperative data, including baseline information of the patients, radiographic parameters, and type of surgical procedure, were collected from the hospital database, and postoperative data, including complications, were collected during the follow-up visit.In all, 33 patients (average, 8.0 ± 2.1 years, male 20, female 13) in the ESIN group and 38 patients (average, 8.3 ± 2.3 years, male 23, female 15) in the ExFix group were included in this study. There was significantly less operative time for the ExFix group (45.4 ± 7.8 min) as compared to the ESIN group (57.8 ± 11.3 min) (P < .01), reduced estimated blood loss (EBL) in the ExFix group (9.9 ± 3.5) as compared to the ESIN group (16.4 ± 6.5) (P < .01). As for the frequency of fluoroscopy, there was a significant difference between the ExFix group (13.9 ± 2.4) and the ESIN group (15.5 ± 3.2) (P = .02). The rate of major complications was not significantly different between the 2 groups (P = .19). The rate of implant irritation was significantly higher in the ExFix group (28/38, 73.7%) than the ESIN group (12/33, 36.4%) (P < .01). The rate of surgical site infection (SSI) is significantly higher in the ExFix group (18/38, 47.4%)) than the ESIN group (1/33, 3%) (P < .01). The rate of scar concern was significantly higher in the ExFix (9/38, 23.7%) than the ESIN (2/33, 6.1%), (P = .04). According to the Flynn scoring system, 30(90.9%) patients in the ESIN group and 24(89.5%) patients in the ExFix group were rated as excellent. None of the patients had poor outcomes.Both ESIN and ExFix produced satisfactory outcomes in distal third femoral shaft fractures. ExFix remains a viable choice for selected cases, especially in resource-challenged and austere settings.

The optimal choice for length unstable femoral shaft fracture in school-aged children: A comparative study of elastic stable intramedullary nail and submuscular plate

The utilization of elastic stable intramedullary nail (ESIN) in length unstable femoral shaft fractures in children remains controversial, and the results in different studies vary a lot. This study aims to investigate the clinical outcomes of ESINs versus submuscular plate (SMP) in length unstable femoral shaft fractures.Patients aged 5 to 11 years old with length unstable femoral shaft fractures treated at our institute from January 2008 to January 2018 were included and categorized into ESIN and SMP group. The preoperative data and operative variables were collected from the hospital database, and postoperative data including complications were collected at follow-up visits.In all, 77 patients (8.1 ± 1.9 years old, male 45, female 32) in ESIN group and 45 patients (8.0 ± 2.2 years old, male 26, female 19) in SMP group were included in this study. Comparing operative variables, there was significantly less operative time, reduced estimated blood loss (EBL) and shortened hospital stay for ESINs as compared with SMP (P < .001). However, the fluoroscopy frequency was not significantly different between these 2 fixation methods (P = .42). As for elective removal surgery, there was significantly reduced operative time, EBL and shortened hospital stay for ESINs as compared with SMP (P < .001).Both ESIN and SMP are safe and effective choices for length unstable femoral shaft fractures in children aged 5 to 11 years. In ESIN, extra care is required to provide additional immobilization using spica cast or brace. Compared with SMP, ESIN is able to deliver comparable clinical outcomes with less EBL, operative time and shorter hospital stay.

Pediatric tibia and femur fractures in patients weighing more than 50 kg (110 lb): mini-review on current treatment options and outcome

The main objective of this paper is to review the current literature on treatment of tibial and femur fractures in children and adolescents guided by body weight in patients weighing 50 kg (110 lb) or more. A secondary aim of this mini-review was to determine, as per literature review, whether weight  > 50 kg (110 lb) is an identifiable factor associated with increased complication rate. A search of the PubMed/MEDLINE, EMBASE and Cochrane Database of Systematic Reviews databases from 1954 to September 2017 was performed to identify papers related to pediatric tibia and femur fractures in children weighing more than 50 kg (110 lb). Abstracts were screened, and relevant full-text articles were retrieved for further review. Reference sections of identified papers were also screened to identify further literature. All levels of evidence were included. Overall, seven full-text articles dealing with pediatric tibia or femur fractures in patients weighing more than 50 kg (110 lb), and one article reporting on both femur and tibia fractures in this patients' population, have been identified (n = 8 full-text article included). The articles reviewed a total of 679 children. In particular, 48/438 femur shaft fractures (mean weight: 51.7 kg or 113.9 lb) and 91/241 tibia fractures (mean weight: 53.3 kg or 117.5 lb) met the inclusion criteria. The overall rate of complications was 27.9%. In particular, the rate of complication was 51.7 and 29.6% in children with femur and tibia fracture weighing more than 50 kg (110 lb), respectively (p < 0.05). Elastic stable intramedullary nailing (ESIN) has become the treatment of choice for displaced tibia and femur shaft fractures in children between six and 12-15 years of age. Unstable fracture pattern, higher age and higher weight have been reported as potential risk factors associated with poor outcomes in children and adolescents treated with ESIN for displaced long bone fractures of the lower extremity, in particular femur shaft fractures. Despite these findings, data reporting exclusively on ESIN-treated long bone fractures in children weighing 50 kg (110 lb) or more remain scant.

Recurrent femoral shaft fractures in a child with gnathodiaphyseal dysplasia: a case report

Background

Gnathodiaphyseal dysplasia (GDD) is an extremely rare autosomal dominant disease characterized by cemento-osseous lesions in the jawbones, bone fragility, and diaphyseal sclerosis of the tubular bones. Patients with GDD are prone to sustain fractures by minor accidents. Although over 80 cases have been reported, detailed information about the orthopedic treatment of the fractures is limited.

Case presentation

A 9-year-old Japanese girl with a known history of GDD presented with pain and deformity in the left thigh after a minor fall. She had a displaced transverse fracture in the mid-shaft of the left femur and underwent a closed reduction and external fixation. In the 25th week after the initial surgery, she had another fracture in the left femur at one of the half-pin insertion sites. She underwent an external fixation again. After this operation, the patient sustained another refracture at the same fracture site and one supracondylar fracture at the distant site of the femur. The supracondylar fracture occurred without any triggering activity before beginning a weight-bearing exercise. The supracondylar fracture was successfully treated conservatively, but she sustained two more diaphyseal fractures at half-pin insertion sites one after another. She eventually underwent a revision surgery with a flexible intramedullary nail. At 3 months postoperatively, the fracture was healed and the patient maintained her ambulatory status without further refracture.

Conclusions

Patients with GDD might have narrower safety ranges of biomechanical and physiological drawbacks, which are considered to be acceptable in ordinary cases. The choice of treatment should be aimed at minimizing these negative effects. We recommend intramedullary devise as the first-choice implant for the treatment of isolated femoral shaft fracture in GDD patients in this age group.

Titanium Elastic Nailing has Superior Value to Plate Fixation of Midshaft Femur Fractures in Children 5 to 11 Years

BACKGROUND

American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines for pediatric femoral shaft fractures indicate titanium elastic nails (TENs) for children 5 to 11 years old. Growing evidence suggests these fractures may also be treated with open or submuscular plating. The purpose of this study was to compare estimated blood loss (EBL), operative time, fluoroscopy time, cost, and subjective and objective pain scores between TENs and plating techniques used in 5- to 11-year-old children with midshaft femur fractures based on length stability. We hypothesized that EBL, operative time, and fluoroscopy time would be greater and pain would be lower with plate fixation.

METHODS

We retrospectively identified all pediatric midshaft femur fractures treated with TENs, submuscular plating, or open plating between 2004 and 2014. Demographic, injury, and surgical data were obtained for analysis. Cost data were obtained from Synthes Inc. Outcomes were determined using the TEN outcome scoring system. Variables were compared between the 3 fixation methods using paired t tests or Fisher exact test as appropriate. Cost data were compared with Mann-Whitney nonparametric test.

RESULTS

There were 65 midshaft femur fractures in 63 patients included. TENs accounted for 77% and plating 23%. There were no statistical differences in injury severity score, length of stay, length unstable fractures, open fractures, fluoroscopy time, or pain. However, there was a significantly greater operative time (P=0.007) and a notably greater EBL (P=0.057) for the plating technique compared with TENs. Patient outcomes were found to be equivalent. Implant cost was not significantly different although increased surgical costs were seen in plating (P=0.0007).

CONCLUSIONS

This study supports the use of TENs or plating for midshaft femur fractures in children 5 to 11 years old, regardless of length stability. The use of plates resulted in higher EBL, longer operative time, increased cost, and equivalent pain compared with TENs. To our knowledge, this study represents the first direct comparison of the common fixation methods specifically for midshaft femur fractures and favors the use of TENs.

LEVEL OF EVIDENCE

Level III.

Spontaneous fetal femoral fracture: a case report and literature review

Spontaneous fetal femoral fractures are uncommon in the paediatric setting. The major clinical presentations of a spontaneous fetal femoral fracture are femoral angulation, shortness of the femur and even a marked fracture line. This case report describes a spontaneous fetal femoral fracture of the right femur, which was detected by routine ultrasonography during the 19^th week of gestation in a 24-year-old woman. On routine follow-up visits, the angulation of the right femur in the fetus gradually improved. A caesarean section was undertaken at 39 weeks +5 days of gestation and an X-ray was taken on the second day after birth, which showed that the fracture had healed and the callus had been absorbed. The lengths of the two femurs of the baby were not equal; the right femur was 84 mm, which was 11 mm shorter than the left femur. In cases like this, postnatal follow-up is essential so that an operation can be carried out in a timely manner when the deformity is apparent.

Elastic Stable Intramedullary Nailing of Femoral Shaft Fracture-Experience in 48 Children

BACKGROUND

Femoral shaft fractures are an incapacitating pediatric injury accounting for 1.6% of all pediatric bony injuries. Management of these fractures is largely directed by age, fracture pattern, associated injuries, built of the child and socioeconomic status of the family. We retrospectively evaluated the use of elastic stable intramedullary nail (ESIN) in surgical management of femoral shaft fractures in children and its complications.

METHODS

Fifty two children were treated with titanium elastic nails (TEN) from June 2009 to June 2014 at our institution. At the end of the study there were 48 children. Fractures were classified according to Winquest and Hansen's as Grade I (n=32), Grade II (n=10), Grade III (n=6) and compound fractures by Gustilo and Anderson's classification, Grade I (n=5), Grade II (n=3). There were 36 mid-shaft fractures, 7 proximal third shaft fractures, 5 distal third shaft fractures. The final results were clinically evaluated by using Flynn's criteria and radiologically by Anthony et al's criteria.

RESULTS

The mean duration of follow-up was 20 months (range 12 - 40 months). All fractures healed radiologically with grade III callus formation at 9 - 12 weeks (mean 9.7 weeks). The results were analyzed using Flynn's criteria and were excellent in 40 children (83%) and satisfactory in 8 children (17%). The soft tissue discomfort near the knee produced by nail ends was the most common problem in our study (25%). Other complications include limb shortening (n=5), Varus malunion (n=4), Nail protruding site infection (n=4) and nail migration (n=2). There was no delayed union, non-union or refractures.

CONCLUSION

TEN is minimally invasive, safe, relatively easy to use and an effective treatment for fracture shaft of femur in properly selected children.Level of evidence: III.

Fracture union in percutaneous Kirschner wire fixation in paediatric tibial shaft fractures

PURPOSE

To evaluate the efficacy of intramedullary Kirschner wires for the treatment of unstable tibial shaft fractures in children.

METHODS

This prospective study was conducted at the Department of Orthopaedic Surgery in Maharishi Markandeshwar Medical College from June 2005 to June 2010. Sixty-six children having closed fracture of the tibial shaft with a mean age of 7.7 years (range, 2-14 years) were recruited from emergency and outpatient department. They were treated with percutaneous intramedullary Kirschner wires. The clinical results of our study were rated on the basis of the criteria of union, nonunion, delayed union or malunion. All children were followed for one year.

RESULTS

Children achieved union in a mean time of 8 weeks (range, 6-10 weeks). Postoperatively, three children (4.55%) had delayed union, one (1.52%) valgus deformity of lower leg, three (4.55%) post- operative knee pain and twelve (18.18%) skin irritation at pin site.Wires were removed after 8-22 weeks without any complications. No patient was lost to follow-up. The results were excellent in 95.45% and good in 4.55% children.

CONCLUSION

This technique is cost-effective, simple, quick to perform, safe and reliable and avoids pro- longed hospitalization with good results.

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.

Use of external fixator versus flexible intramedullary nailing in closed pediatric femur fractures: comparing results using data from two cohort studies

PURPOSE

Although external fixation and flexible intramedullary nailing have been extensively used in the management of pediatric femur fractures, there are very few studies, which have compared the results. The purpose of the study was to compare the results of external fixation and flexible intramedullary nailing in pediatric femur fractures.

METHODS

Two groups of patients were treated by external fixator (EF) and flexible intramedullary nailing (FIN) over two different but successive time periods and results compared. The first group (EF) consisted of 45 patients, and the second group had 50 patients.

RESULTS

The age in EF group ranged from 6 to 14 years (average 9.93 years), and the age in FIN group ranged from 6 to 11 years (average 7.66 years). In the EF group, fixator was removed at an average of 12.23 weeks. In the FIN group, radiographic union was evident at an average time of 10.06 weeks. Pin-site infection was common in EF group. One patient had a re-fracture in EF group, and one patient had to be re-operated in FIN group after he developed anterior angulation of more than 30°.

CONCLUSION

We believe that it is the discretion of the surgeon to operate on the femur fracture using either of the treatment modalities. Further randomized studies need to be conducted between these two treatment modalities.