The outcomes of pediatric femoral shaft fractures treated surgically by different types of orthopedists

Clinical Efficacy of Minimally Invasive Elastic Stable Intramedullary Nailing for Limb Long Bone Fractures in Children

Objective

The aim of the present paper was to investigate the clinical efficacy of minimally invasive elastic stable intramedullary nailing (ESIN) for long bone fractures in children.

Methods

A total of 350 children with limb fractures from June 2012 to June 2018 were recruited and randomized into two groups: an ESIN group (n = 175) treated with elastic stable intramedullary nailing, and an MPIF group (n = 175), treated with metal plate internal fixation. Both groups received the same physical examination and routine medication. Operation related indexes, clinical efficacy, complications, and postoperative quality of life scores were analyzed and compared.

Results

The operation time, intraoperative blood loss, hospitalization time, and fracture healing time in the ESIN group were 43.74 ± 4.96 min, 8.14 ± 1.34 mL, 5.97 ± 1.88 days, and 55.89 ± 5.61 days, respectively, which were all significantly less than those in the MPIF group (all P < 0.001). In terms of common complications after limb fracture treatment, there were 6 cases of osteomyelitis, 5 cases of skin irritation response, and 7 cases of inflammatory granuloma in the MPIF group. There were 2 cases of skin irritation response and 5 cases of inflammatory granuloma in the ESIN group. The incidence of postoperative complications in the ESIN group was 4.00%, which was significantly lower than that in MPIF group (10.29%) (P < 0.05). The effective rate for recovery condition in the ESIN group (93.71%) was significantly higher than that in the MPIF group (P < 0.001). The quality of life scores after treatment in both groups were improved, while the score in the ESIN group was significantly higher than that in the MPIF group (79.43%) (P < 0.001). The postoperative satisfaction rate in the ESIN group (94.29%) was significantly higher than that in the MPIF group (86.29%) (P < 0.05). The quality of life scores after treatment in both groups were improved, while the score in the ESIN group was significantly higher than that in the MPIF group (P < 0.001). The postoperative satisfaction rate and the acceptance rate for adjacent joint function in the ESIN group (100%) were significantly higher than those in the MPIF group (92.00%) (P < 0.0001).

Conclusion

Elastic stable intramedullary nailing is a minimally invasive procedure for long bone fractures in children. It can effectively improve the operation‐related indicators and postoperative quality of life and reduce the incidence of complications.

Predictors of Open Reduction in Pediatric Femur Fractures Treated With Flexible Nails

BACKGROUND

Closed reduction (CR) is sufficient to reduce the majority of femur fractures treated with flexible intramedullary nailing (FIN). No previous study has examined factors associated with failed CR of pediatric femoral shaft fractures treated with FIN. We sought to determine preoperative factors associated with failed CR. We hypothesized that fracture, patient, and surgeon characteristics would impact the need for open reduction (OR).

METHODS

A retrospective review of children treated for femur fracture between 2012 and 2017 at a tertiary pediatric hospital was performed. Comparisons were made between 2 groups: FIN with CR group and FIN that required OR group. Demographic and baseline characteristics were compared between treatment groups using either χ tests or Fisher exact tests for categorical variables and general linear models for continuous variables. Odds ratios with 95% confidence intervals were calculated using univariate logistic regression tests.

RESULTS

Of 449 consecutive pediatric femur fractures treated at our center, 85 children were treated with FIN and constituted the study cohort. CR failed in 14 patients (16.5%) necessitating OR of the fracture site. Significant differences between study groups were found in fracture location (P=0.018), the mechanism (P=0.003), and displacement on the anteroposterior radiograph (P=0.027). Surgical time was found to be longer in the OR group (P=0.010). We identified 3 preoperative predictors of OR for FIN including fractures caused by high energy mechanisms (odds ratio=7.5), distal third fractures (odds ratio=15.3), and fracture displacement on the anteroposterior view (odds ratio=1.06). Surgeon years in practice, patient weight, age, and time from injury to surgery were not associated with OR.

CONCLUSIONS

This study presents 3 preoperative risk factors that predict the need for OR of femur fractures treated with FIN. Surgical time was longer in cases that required OR. Our findings suggest that surgeons should avoid lengthy attempts at CR and consider a lower threshold for OR of at-risk fractures or use another technique other than flexible nails.

LEVEL OF EVIDENCE

Level III-prognostic.

"Who is the right patient?" Insights into decisions to transfer pediatric trauma patients

OBJECTIVE

We aim to determine what variables may influence physician decision-making about transfer of pediatric patients from a Level III Trauma Center (L3TC) to a Pediatric Trauma Center (PTC).

METHODS

Emergency L3TC physicians and PTC emergency physicians/TTLs were surveyed with clinical scenarios of children presenting to a L3TC with 5 injury parameters: age, hemodynamic status, GCS, intra-abdominal injury, femur/ pelvic fracture, and asked if the patient should be transferred to a PTC. Associations between parameters and physician demographics in the decision to transfer were examined.

RESULTS

One hundred seven and 94 surveys were completed at L3TCs and PTCs, respectively. Parameters associated with decision to transfer: pelvic and GI tract injuries, GCS < 12, and age < 4 years. L3TCs were significantly less likely vs. PTCs to recommend transfer with femur fracture, solid organ / GI injury, or a GCS of <13. Increasing town size, access to an experienced surgeon, and formal training in emergency medicine among L3TC physicians were associated with a decision not to transfer.

CONCLUSIONS

Injuries requiring potential surgery or critical care influenced the decision to transfer. For cases with lesser severity or older ages, input of L3TCs on developing triage criteria is vital to allow families to stay in their home communities while ensuring optimal clinical outcomes.

TYPE OF STUDY

Prospective Cross Sectional Survey.

LEVEL OF EVIDENCE

Level III.

Treatment of Closed Femoral Shaft Fractures in Children Aged 6 to 10

BACKGROUND

Management of pediatric femoral shaft fractures remains controversial, particularly in children between the ages of 6 and 10. In the current push toward cost containment, hospital type, and surgeon subspecialization have emerged as important factors influencing this treatment decision. Thus, in the present study, we use a nationwide pediatric inpatient database to compare the: (a) incidence; (b) demographic characteristics; (c) hospital costs; (d) length of stay; and (e) treatment method of pediatric closed femoral shaft fractures admitted to general versus children's hospitals.

METHODS

The Kids' Inpatient Database (KID) was queried for all patients aged 6 to 10 who sustained a closed femoral shaft fracture in 2009 or 2012, and patient records were stratified into children's hospitals and general hospitals. Primary outcome measures included method of treatment, total hospital costs, and length of stay. Student/Welch t testing and χ analysis were utilized to compare continuous and categorical outcomes, respectively, between hospital types.

RESULTS

The total incidence of closed femoral shaft fractures decreased between 2009 and 2012 (1919 to 1581 patients; P=0.020), as did the proportion of patients treated in children's hospitals (58.6% to 32.3%; P<0.001). In addition, patients treated at general hospitals were more likely to receive open reduction with internal fixation (45.3% vs. 41.1%) or external fixation (4.1% vs. 2.3%), and less likely to be managed with closed reduction with internal fixation (32.0% vs. 39.7%) than those treated at children's hospitals (P<0.001 for all).

CONCLUSIONS

The present study demonstrates a decrease in the incidence of closed femoral shaft fractures in 6- to 10-year old patients from 2009 to 2012, as well as decreased definitive management in children's hospitals and increased selection of operative treatment. In addition, treatment in a nonchildren's hospital was associated with decreased total inpatient costs and decreased treatment with closed reduction with internal fixation in favor of open reduction with internal fixation. Future studies should seek to identify the specific surgical procedures performed and match patients more closely based specific fracture pattern.

LEVEL OF EVIDENCE

Prognostic level II.

Titanium elastic nailing in pediatric femoral diaphyseal fractures in the age group of 6-15 years mid-term and long-term outcomes

Objective:

To evaluate the effectiveness of Titanium Elastic Nailing (TEN) used in the surgical treatment of pediatric femoral shaft fractures and the effect of the complications to the outcome. Another objective was to assess the changing of Limb Length Discrepancy (LLD) and angulation degree with prolonged follow-up time and to evaluate whether the patient had a functional problem because of this situation.

Methods:

Thirty children between the ages of 6 and 15 who had femur shaft fractures were evaluated. The times of operation, ambulation, bone union and follow-up were recorded. Post-operative complications were evaluated between 1996-2016 with at least 24 Months follow up.

Results:

The mean follow-up was 52.5 ± 49.0 months (range 24-240). The mean varus angulation was 3.2 ± 5.1 degrees. The length of the fracture side was approximately 0.71 ± 0.58 cm (range 0-2.09 cm) longer than the intact side. There were eight patients with LLD of 1-2 cm. There was no statistically significant relationship between the type, location, and age of fracture of the LLD (P> 0.05). It was evaluated according to Flynn’s criteria. According to this, 12 (40%) of the patients’ results were excellent, 14 (46.7%) were good, and four were poor.

Conclusion:

TEN is an effective, easy, fast treatment method and has minimal complications for the treatment of femoral shaft fractures in childhood. Most complications can be reduced by performing basic principles and technical directions. Although LLD is a common complication of childhood femur fractures, the disease does not present a functional problem in daily life.

Comparison of the outcomes of pediatric tibial shaft fractures treated by different types of orthopedists: A prospective cohort study

BACKGROUND

The objective of this study was to compare the outcomes of pediatric tibial shaft fractures treated with titanium elastic nail (TEN) by pediatric orthopedists and non-pediatric orthopedists.

MATERIALS AND METHODS

We conducted a prospective cohort study of 90 children of tibial shaft fractures, who were randomized to operative stabilization either by pediatric orthopedists (Group A, 45 cases) or by non-pediatric orthopedists (Group B, 45 cases) from April 2010 to May 2015. Demographic data and clinical characteristics (age, sex, weight, fracture side and type, cause of injury, number of fibula fracture and time from injury to operation) were comparable between the two groups before surgery. Clinical data, complications and functional outcomes between the two groups were recorded.

RESULTS

A total of 10 patients were lost to follow-up for various reasons and each group remained 40 cases. The mean follow-up period was 14.9 ± 1.9 months for Group A and 15.3 ± 2.2 months for Group B (P = 0.451). There was no significant difference in length of hospitalization, full weight-bearing time, fracture union time and TEN outcome scores between the two groups (P = 0.917, P = 0.352, P = 0.404, P = 506, respectively). However, Group A exhibited significantly shorter operation duration and less fluoroscopy times than Group B (P < 0.001 and P < 0.001, respectively). Also, there was a trend for patients of Group A to have lower rate of open reduction than Group B (P = 0.019). When comparing the total complications, no significant difference existed between the groups (P = 0.764).

CONCLUSIONS

Our results indicated that pediatric tibial shaft fractures treated surgically by pediatric orthopedists offered potential advantages including a shorter operating time, less times of fluoroscopy and a lower rate of open reduction. However, both pediatric and non-pediatric orthopedists could achieve satisfactory clinical results in treatment of these injuries.