The measurement of the rotational deformities with computed tomography in femoral shaft fractures of the children treated with early spica cast

Elastic Stable Intramedullary Nailing in Length Stable Versus Unstable Pediatric Femoral Shaft Fractures: A Comparison of Clinical, Radiographic, and Pedobarographic Outcomes

BACKGROUND

Pediatric diaphyseal femoral fracture (PDFF) is one of the most common injuries requiring hospitalization. Elastic stable intramedullary nailing (ESIN) is commonly used for PDFFs in ages 5 to 11. The optimal treatment method for length unstable PDFF is a subject of ongoing debate. This study aimed to compare clinical, radiographic, and pedobarographic outcomes of ESIN between length stable and unstable PDFF.

METHODS

We retrospectively reviewed patients undergoing ESIN treatment for isolated PDFF between 2016 and 2021. Exclusion criteria were (1) history of ipsilateral or contralateral lower extremity fractures, (2) highly comminuted or segmental fractures, (3) body weight >50 kg, and (4) comorbidities affecting bone quality, range of motion, or neurologic status. The patients were divided into 2 groups according to length stability. Clinical, radiographic, and pedobarographic data were then assessed to compare groups.

RESULTS

Twenty-five patients were included (17 length stable and 8 length unstable PDFF) with a mean age of 73.6±17.8 months. There was no significant difference between groups in age, side of injury, body weight, follow-up duration, and nail-canal diameter ratio. Mean deformity in the fracture site in the early postoperative x-rays was not significantly different between groups ( P =0.661). After a mean follow-up of 27.8±14.2 months (range, 12-67), there was no significant difference in mechanical axis deviation, distal femur joint orientation angle, or limb-length discrepancy in both groups. The pedobarographic assessment revealed that the length unstable group had a significantly higher external foot progression angle in the injured extremity (9.8°±6.9° vs. 1.3°±5.6°, P =0.031). However, the length stable group had no significant difference in the foot progression angle (4.9°±5° vs. 3°±4.3°, P =0.326). There was no significant difference in either group for other pedobarographic parameters.

CONCLUSION

ESIN is a safe and effective option for length-unstable PDFF, yet attention should be paid to the rotational alignment. Although significant external rotation deformity occurs in length-unstable PDFF, it has no implications for the other pedobarographic parameters.

LEVEL OF EVIDENCE

Level IV.

Effect of rotational deformities after pediatric femoral fracture on clinical outcome

Femoral shaft fractures are the most common pediatric injuries that require hospitalization. Early closed reduction and spica casting are one of the most popular treatment options. One of the significant complications of spica casting is rotational deformities of the fracture. The present study aimed to determine the potential effects of rotational deformities in pediatric patients who underwent early spica casting after a femoral shaft fracture. Pediatric patients who underwent early spica casting following femoral shaft fractures were screened retrospectively. Radiological measurements were made on the patients' initial postop radiographs who could be measured rotationally according to the defined radiological method. Twenty-three patients with more than 10° of rotation in their measurements were included in the study. Differences in leg length and rotation between both legs were calculated with clinical examination methods for all patients in the study. The gaits of the patients were observed; patient and family complaints were obtained. We found a strong and positive correlation between the rotational measurement made on the X-ray and the clinical measurement (R: 0.634, P: 0.001). For measurements made on X-ray, the mean rotational value was calculated as 27.2 ± 6.9 degrees. After the patients' clinical examination, an average of 3.0 ± 1.7 degrees rotational difference was found between the broken limb and the healthy limb. No patient or family complained of trauma. Early spica casting, according to the age of the patient, is an effective treatment method. There may still be certain degrees of deformity after treatment, but patients well tolerate them even at high degrees. Accordingly, it was concluded that the rotational deformities less than 30 degrees would not cause clinical problems on children under 4 years of age which may require postoperative revisions or the use of various costly imaging techniques and include radiation.

Femoral malrotation after surgical treatment of femoral shaft fractures in children: a retrospective CT-based analysis

BACKGROUND

Rotational malalignment is an important and not always avoidable complication after surgical treatment of femoral shaft fractures. The purpose of this study was to determine the incidence of rotational malalignment in children after surgical treatment of femoral shaft fractures and to identify potential patient- and treatment-related risk factors based on data obtained from CT scans.

METHODS

We conducted a retrospective analysis of all patients aged less than 15 years with femoral shaft fractures admitted to our level 1 trauma centre between January 2004 and July 2014. Patients having obtained postoperative CT scans were included for the determination of rotational malalignment. A difference of greater than 15° in femoral torsion between both legs was considered as clinically relevant. Additionally, demographic data and clinical information such as fracture type, treatment method, fluoroscopy time and operating time were reviewed.

RESULTS

A total of 24 patients were enrolled in this study. Clinically relevant femoral malrotation was identified in 10 patients (41.6%). Surgical revision was performed in 7 patients (29.2%). There was no association between the type of surgical procedure, age and the incidence and/or amount of femoral malrotation.

CONCLUSIONS

The data suggest that relevant femoral malrotation is an evident problem after surgical treatment of femoral shaft fractures in children that requires critical postoperative assessment.

LEVEL OF EVIDENCE

Level III, retrospective study.

Measurement of Malrotation on Direct Radiography in Pediatric Distal Radius Fractures: Prospective Observational Study

The aim of this prospective study was to test a mathematical method of measuring the malrotation of pediatric distal radius fractures (PDRFs) from direct radiographs. A total of 70 pediatric patients who presented at the Emergency Department with a distal radius fracture were evaluated. For 38 selected patients conservative treatment for PDRF was planned. Anteroposterior and lateral radiographs were taken of all of the patients for comparison before and after reduction. Radius bone diameters were measured in the coronal and sagittal planes on the healthy and fractured sides. Using the diameter values on the healthy side and the new diameter values on the fractured side in the rotation formula, the degree of malrotation between the fracture ends was calculated. The mean follow-up period was 13.5 months. Patients' mean age was 10.00 ± 3.19 years (range, 4-12 years). The rotation degree in the sagittal plane significantly differed between the proximal (26.52°±2.84°) and distal fracture ends (20.96°±2.73°) (P = 0.001). The rotation degree in the coronal plane significantly differed between the proximal (26.70°±2.38°) and distal fracture ends (20.26°±2.86°) (P = 0.001). The net rotation deformity of the fracture line was determined to be 5.55°± 3.54° on lateral radiographs and 5.44°± 3.35° on anteroposterior radiographs, no significant difference was observed between measurements (P >0.05). The malrotation deformity in PDRF occurs with greater rotation in the proximal fragment than in the distal fragment. The net rotation deformity created between the fracture ends can be calculated on direct radiographs.

LEVEL OF EVIDENCE

Diagnostic, Level II.

Calculation of pediatric femoral fracture rotation from direct roentgenograms

Background

Radiologic determination of pediatric femoral fracture rotation has been debated. Measuring the antetorsion angle of the fractured femur by computed tomography and comparing it with the opposite side has been the method of choice for this purpose. However, no simple method for direct measurement of femoral fracture rotation exists in the literature. In this study, our aim was to test a mathematical method of measuring the axial plane malrotation from direct roentgenograms.

Materials and methods

A pediatric femoral shaft fracture model was produced. The bone was secured to a wooden frame that allowed the distal part of the fracture to rotate around an axis. Radiographs were taken at known intervals of rotation ranging from the neutral position to 60° external rotation and to 60° internal rotation in 5° increments of rotation. Five independent, blinded observers measured the radiographs and calculated the fracture rotation according to a standard formula. Calculated rotation values were compared with known rotation values.

Results

Calculated rotation values were close to actual rotation values throughout the arc of rotation. The mean absolute error of five observers for all measurements of external and internal rotation was 3.97° (±0.83). The correlation coefficient between calculated and actual rotation values was 0.9927. The interobserver intraclass correlation coefficient for calculated rotation was 0.997.

Conclusions

Absolute error and correlation coefficient values indicate that this method is accurate and reliable in determining the fracture rotation.