Femoral Shaft Fractures In Patients Research Articles

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.

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. 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 113mo). 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. 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. 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 40kg or with unstable fracture patterns. Level III, retrospective cohort study. See the Guidelines for Authors for a complete description of levels of evidence.

Should Femoral Shaft fractures in Patients Age Over 60 Years be Managed Using a Hip Fracture Pathway?

The British Orthopaedic Association published 2019 guidelines 'The Older or Frail Orthopaedic Trauma Patient'. This implements principles of the hip fracture pathway to all fragility fractures. Like hip fractures, femoral shaft fractures in the elderly are also suggested to represent fragility fractures. Femoral shaft fractures in older patients are rare and there is scarce literature detailing their outcomes. We aim to review outcomes of femoral shaft fractures in patients age 60 years and over at our institution and compare them to that of the hip fracture population. We retrospectively reviewed clinical records of a consecutive cohort of patients aged 60 years and over, who sustained a femoral shaft fracture, over a five-year period at our institution. Outcome measures studied were time to surgery, mean length of admission, readmission rate within 30 days, medical and orthopaedic complications, one month and one year mortality. We identified 53 patients with a mean age of 78.7 years. On average patients each had 2.7 medical comorbidities. Mean length of admission was 20.0 days and readmission rate within 30 days was 19.1% (n=9). Medical complications affected 41.5% of patients (n=22) and orthopaedic complications affected 9.4% of patients (n=5). Two patients demonstrated nonunion and one patient required revision surgery. Thirty day mortality rate was 13.2% (n=7) which increased to a one year mortality of 26.4% (n=14). Patients age 60 years and over with femoral shaft fractures have poor medical outcomes and prolonged length of admission. Compared to patients with hip fractures, medical complication rates are at least twice the 13-20% reported for hip fractures. The 30 day mortality rate in patients with femoral shaft fractures was also more than double the 6.1% reported for hip fracture patients by The National Hip Fracture Database in 2018. Femoral shaft fractures are associated with high medical morbidity and mortality. The hip fracture pathway is encompassed in the British Orthopaedic Association guidelines and emphasizes early medical input and a multidisciplinary approach to patient management. Hence, our study supports implementation of these guidelines with aim to improve morbidity and mortality of this vulnerable patient group.

Peri-implant femoral shaft fracture in patient with healed femoral neck fracture treated operatively using Targon FN system

Peri-implant femoral shaft fracture in patient with healed femoral neck fracture treated operatively using Targon FN system

Percutaneous titanium elastic nail for femoral shaft fracture in patient between 5 and 15 years

Femoral shaft fracture is the commonest major pediatric orthopedic injury requiring hospitalization. Controversy persists regarding management of femoral fractures in the patients aged between 5–15 years.11 patients were followed up for the mean period of 12 months and evaluated using Flynn’s criteria. All the fractures united between 8–12 weeks. 3 patients had knee stiffness, 1 patient had shortening > 2 cm and 1 had superficial infection.We conclude that TENs is simple, rapid & effective treatment for displaced pediatric femoral shaft fractures between 5–15 years of age with very less complication rate.

Do demographic and perioperative parameters really affect the final outcomes of pediatric femur shaft fractures managed by elastic nails? A prospective study

ObjectivePediatric femoral shaft fractures are more commonly treated with intramedullary titanium elastic nail system (TENS). Adhering to the principles, most studies had supported excellent results with this instrumentation and attributed the variation in age, weight, immobilization protocols, technical factors like fracture pattern, reduction and complications as reasons to poor outcomes in their individual studies. Hence, we wanted to identify the potential demographic and perioperative parameters that could affect the final outcomes in this cohort. MethodsA prospective (level III) study done in a single center between November 2013 and January 2017 on isolated closed femoral shaft fractures in patients of age between 6 and 15 years managed with TENS. The demographic and perioperative parameters were recorded. The patients were followed up regularly with plain radiographs. The final outcomes were computed at end of one year and recorded as poor, satisfactory and excellent as defined by Flynn criteria. ResultsAmong the thirty patients included, mean age was 8.2 years. 80% of the patients weighing over 40 kg had satisfactory to poor outcomes. (p = 0.005). 45% of patients with proximal and distal level fractures that were long oblique spiral or comminuted types had satisfactory outcomes; however it was not statistically significant. The mean delay to surgical fixation was 5.87 days, surgical time was between 45 and 150 min and open reduction was required in about 17 cases (57%). Patients with immobilization beyond 6 weeks had satisfactory outcomes (p = 0.001). We had 5 patients with minor complications (4 bursitis and 3 superficial infections) and one major complication (chronic osteomyelitis and deep venous thrombosis) leading to satisfactory and poor outcomes respectively. Significant osseous union was noted between 6 and 11 months with 97% of patients attaining union within 9 months. ConclusionsIntramedullary TENS is an excellent modality to treat femoral shaft fractures in patients of school going age. However, factors like weight of the patient >40 kg, immobilization beyond 6 weeks, minor and major complications in the perioperative period could pose risks for poor to satisfactory outcomes and should be anticipated and explained accordingly.

Flexible Intramedullary Nails for Femur Fractures in Pediatric Patients Heavier Than 100 Pounds.

Flexible intramedullary nailing (FIMN) of femoral shaft fractures in children >100 pounds remains controversial. The purpose of this study is to assess the relationship between patient weight and alignment at radiographic union following Ender's FIMN of pediatric femoral shaft fractures. An IRB approved, retrospective review of all patients who sustained a femoral shaft fracture treated by retrograde, stainless-steel Ender's FIMN was performed at a level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. Patient weight was measured on presentation to the emergency room. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation. A total of 261 children underwent Ender's FIMN for femoral shaft fractures during the study period. There were 24 patients who weighed ≥100 lbs and 237 patients who weighed <100 lbs. There were no significant differences in sex (75% vs. 73% male), fracture stability (42.6% vs. 41.7% length unstable), or fracture patterns between the 2 groups. The ≥100 lbs group was significantly older (10.6 vs. 8.0 y, P<0.001). There were no significant differences in final coronal angulation (1.5 vs. 3.0 degrees), sagittal angulation (2.8 vs. 3.1 degrees), or shortening (3.4 vs. 3.5 mm) between the 2 groups. There were significantly more nail removals in the <100 lbs group (81.4% vs. 66.7%, P<0.01). Four percent of the population (10 patients) weighed ≥120 lbs and aside from age (11.4 vs. 8.1 y, P<0.01), there were no significant demographic or fracture pattern differences between this group and the remaining population. This heaviest group demonstrated no significant difference in shortening (3.3 vs. 3.5 mm), coronal angulation (0.8 vs. 3.0 degrees), or sagittal angulation (0.7 vs. 3.2 degrees) at radiographic union when compared with the lighter patients. Stainless-steel Ender's FIMN is an effective treatment for pediatric femoral shaft fractures in patients ≥100 pounds with excellent radiographic outcomes and no increased risk for malunion. Therapeutic Level III.

Timing of Femoral Shaft Fracture Fixation Affects Length of Hospital Stay in Patients with Multiple Injuries.

Purpose : Appropriate timing of definitive fracture care in the setting of polytrauma remains controversial. The aim of this study is to determine whether timing of definitive fixation of femur fractures impacts subsequent length of hospital stay, a surrogate for postoperative morbidity, in patients with multi-system trauma.Methods : Secondary analysis of data from the National Trauma Data Bank (January 1, 2000 to December 31, 2004) was performed. Adult patients who: (1) had an open or closed femoral shaft fracture, (2) had an injury severity score (ISS) greater than or equal to 15, (3) and underwent definitive internal fixation were included. Time to fixation was divided into 5 time periods based on commonly used cut-off points from the literature: (1) 12 hours or less, (2) between 12 and 24 hours, (3) between 24 and 48 hours, (4) between 48 and 120 hours, and (5) more than 120 hours. Because we consider length of stay a surrogate for adverse outcome causally affected by treatment time, the outcome variable was calculated as the duration of hospitalization following definitive treatment. Time to definitive fixation and its effect on post-treatment length of hospital stay was analyzed using median regression with inverse probability of treatment-weighting (IPTW) to control for confounding factors.Results : Compared to fixation during the first 12 hours after admission, median length of hospital stay was significantly higher (2.77 days; 95% confidence interval, 0.54 to 4.72) when fixation occurred between 48 and 120 hours from admission. Among the other time intervals, only treatment between twelve to twenty-four hours after admission was shown to reduce length of stay (-0.61 days; 95% confidence interval, -1.53 to 0.42) versus the referent interval of the first 12 hours, though this result did not achieve statistical significance. In order to assess the impact of shorter recorded length of stay for deceased patients, sensitivity analysis was conducted excluding all patient that underwent definitive treatment and died. Results were nearly identical for the second analysis, showing a higher post-treatment length of stay estimated for the population treated between 48 and 120 hours versus had they been treated within the first 12 hours from admission (2.53 days, 95% confidence interval, 0.27 to 4.13).Conclusion : Delayed fixation of femoral shaft fractures in patients with multiple injuries between 2-5 days may lead to an increase in adverse outcomes as evidenced by increased median length of hospital stay. This finding supports prior clinical reports of a perilous period where a “second hit” resulting from definitive internal fixation can occur. Whether there is an optimal window for fixation during which physiologic stress of fracture fixation does not adversely lengthen hospital stay should be the subject of future prospective study.

The management of femur shaft fracture associated with severe traumatic brain injury

The aim of this article is to describe the management of femoral shaft fractures in patients with severe traumatic brain injury (TBI). This is a major problem and two questions remain currently of interest: When and how to perform orthopedic surgery in severe TBI patients? The main point of perioperative management remains the prevention of secondary brain insults and the monitoring of intracranial pressure is essential especially in patients with intracranial lesions on the CT-scan. The “double hit” concept, suggesting that surgery by itself might increase the preexisting systemic inflammatory response, gives argument for very early or delayed surgery. Early definitive femoral osteosynthesis, if requires lengthy surgical procedure, does not seem appropriate in this context and “damage-control orthopedics” with external fixation seems to be a good alternative.

Bilateral low-energy sequential femoral shaft fractures in patients on long-term bisphosphonate therapy

The aim of this study was to evaluate the demographic characteristics of patients with bilateral bisphosphonate-related low-energy femoral shaft fractures. The clinical registry was reviewed for patients with bisphosphonate-related low-energy fractures localized at femoral shaft between January 2008 and January 2012. Patients with a diagnosis of postmenopausal osteoporosis, bisphosphonate usage of at least 5 years and prodromal pain prior to fracture were included the study. Five women met the inclusion criteria. All patients had bilateral low-energy sequential femoral shaft fractures. Fracture patterns were similar and atypical (transverse-short oblique fractures with lateral cortical thickening). Mean period of bisphosphonate treatment was 8.6 years. Mean patient age was 76.2 years. Union time of three patients was between 20 and 28 weeks. The remaining two fractures were revised for delayed union or nonunion. Long-term (over 5 years) use of bisphosphonates may cause insufficiency fractures due to increased fragility and brittleness which have a close relationship with depressed bone remodeling. While there is still no causal relationship between bisphosphonates and atypical, low-energy femoral shaft fractures, we have some concerns about the optimal usage time and long-term safety of bisphosphonate drugs.

Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries

Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries

Timing of definitive treatment of femoral shaft fractures in patients with multiple injuries

Optimal timing of definitive treatment of femoral shaft fractures in patients with multiple injuries remains controversial. This study aimed to determine the impact of timing of definitive treatment (early, delayed, or damage-control orthopedics [DCO]) of femoral shaft fractures on the incidence of adult respiratory distress syndrome (ARDS), mortality rate, and hospital length of stay (LOS) in patients with multiple injuries. A systematic review of published English-language reports using MEDLINE (1946-2011), Embase (1947-2011), and Cochrane Library. Search terms included femoral fractures, multiple trauma, fracture fixation, and time factors. This study reviewed randomized and nonrandomized studies that (1) compared early and delayed treatment or early treatment and DCO and (2) reported the incidence of ARDS, mortality rate, or LOS. Extraction of articles was performed by one of the authors using predefined data fields. Thirty-eight studies met our inclusion criteria. Studies were grouped into heterogeneous injuries with early versus delayed treatment (17 studies), heterogeneous injuries with early versus DCO (8 studies), head injury (13 studies), and chest injury (7 studies). Most of the studies (≥ 50%) reporting ARDS and mortality rate showed no difference in each of these groups. However, 6 of 7 and 2 of 3 studies reporting LOS in the heterogeneous injuries with early versus delayed and heterogeneous injuries with early versus DCO, respectively, showed shorter stay for early treatment. Pooled analyses were not conducted owing to changes in critical care delivery during the study period and variations in definitions of early treatment, ARDS, and multiple injuries. Thirty-five reports were based on nonrandomized trials and were subject to biases inherent in retrospective studies. The review process was limited by language and publication status. The literature suggests that early definitive treatment may be used safely for most patients with multiple injuries. However, a subgroup of patients with multiple injuries may benefit from DCO [corrected]. Systematic review, level III.

Atypical bilateral femoral shaft fracture in patient treated with bisphosphonates

We report a patient with previous history of long-term bisphosphonate intake who suffered the fracture of both femurs consecutively. The radiological characteristics of both fractures allowed to catalog a posteriori of atypical fractures associated with the prolonged treatment with bisphosphonates. Atypical fractures represent an entity of recent definition that in the last years have attracted considerable attention due to the publication of an increasing number of cases. The aim of this paper is to emphasize the importance of its clinical suspicion before they appear and the characteristics of this type of fractures to provide the most appropriate clinical and surgical treatment.

Bisphosphonate-associated femoral fracture: implications for management in patients with malignancies

Reports of femoral shaft fractures in patients on long-term bisphosphonates (BPs) have raised important concerns on the safety for this class of drugs. Patients with malignancies are potentially at a higher risk for this complication considering the dose and the duration of treatment with BPs. In this report we describe the case of 56-year-old woman with multiple myeloma who developed a non-traumatic left femoral shaft fracture after treatment with high dose BPs for 6 years, following a bone marrow transplant. Intramedullary rod fixation of the fractured femur resulted in "splitting" of the fractured bone followed by poor healing and nonunion of the fractured bone. This case illustrates a potential problem in the management of patients with femoral shaft fractures from prolonged BPs, most especially those who are on high doses for malignant conditions. However, considering the number of patients who benefit from BPs, this complication should not discourage clinicians from using these agents in patients where treatment is indicated.

Impact of the Method of Initial Stabilization for Femoral Shaft Fractures in Patients With Multiple Injuries at Risk for Complications (Borderline Patients)

Impact of the Method of Initial Stabilization for Femoral Shaft Fractures in Patients With Multiple Injuries at Risk for Complications (Borderline Patients)

Results of Femoral Intramedullary Nailing in Patients Who are Obese Versus Those Who are not Obese: A Prospective Multicenter Comparison Study

Antegrade femoral nailing through a piriformis fossa starting point in patients who are obese has been demonstrated to be problematic. Retrograde femoral nailing therefore has been advocated in this patient population, but little data exist to support such a recommendation. The purpose of this study was to evaluate and compare antegrade and retrograde femoral nailing technique in both patients who are and are not obese. Prospective, multicenter, nonrandomized, internal review board (IRB)-approved study. Four Level 1 trauma centers. Patients (151) with a femoral shaft fracture (OTA 32) treated with intramedullary nailing were studied. Thirty-two with a body mass index (BMI) of >or=30 comprised the obese group (OG), and 119 with a BMI of <30 comprised the nonobese group (NOG). Antegrade nailing was performed in 15 patients from the OG and 84 from the NOG. Retrograde nailing was performed in 17 patients from the OG and 35 from the NOG. Reamed intramedullary nailing of a femoral shaft fracture. Patient and fracture characteristics, operative time, fluoroscopy time, healing, complications, and functional outcome based on the lower extremity measure (LEM) were evaluated. Antegrade technique in the OG was associated with a 52% greater average operative time (94 minutes) compared with antegrade nailing in the NOG (62 minutes; P < 0.003). For retrograde nailing technique, there was no difference in the average operative time between the OG (67 minutes) and NOG (62 minutes; P = 0.51). Antegrade technique in the OG was associated with a 79% greater average radiation exposure time (247 seconds) compared with antegrade nailing in the NOG (135 seconds; P < 0.03). For retrograde nailing technique, average fluoroscopy time was similar between the OG (76 seconds) and the NOG (63 seconds; P = 0.44). Within the OG, antegrade nailing required 40% greater average operative time (94 minutes versus 67 minutes, P < 0.02) and more than 3 times more average fluoroscopy time (242 seconds versus 76 seconds, P < 0.002) than retrograde nailing. Thirty-eight patients from the original cohort were not available for follow-up. Of the 113 patients followed (average 9 months, range: 4 to 25 months), healing complications occurred similarly between the 2 groups, with 1 nonunion and 2 delayed unions in the OG (12%), and 3 nonunions and 9 delayed unions in the NOG (14%). This study provides evidence, in the form of decreased operative and radiation exposure times, to support the use of retrograde nailing technique for the treatment of femoral shaft fractures in patients who are obese. Also, antegrade nailing was found to require significantly more operative and radiation exposure time in the patient who is obese as opposed to the patients who is not obese. Although having similar baseline functional scores, patients who are obese recovered at a slower rate and more incompletely than patients who are not obese.

Impact of the Method of Initial Stabilization for Femoral Shaft Fractures in Patients With Multiple Injuries at Risk for Complications (Borderline Patients)

The timing of definitive fixation for major fractures in patients with multiple injuries is controversial. To address this gap, we randomized patients with blunt multiple injuries to either initial definitive stabilization of the femur shaft with an intramedullary nail or an external fixateur with later conversion to an intermedullary nail and documented the postoperative clinical condition. Multiply injured patients with femoral shaft fractures were randomized to either initial (<24 hours) intramedullary femoral nailing or external fixation and later conversion to an intramedullary nail. Inclusion: New Injury Severity Score >16 points, or 3 fractures and Abbreviated Injury Scale score > or =2 points and another injury (Abbreviated Injury Scale score > or =2 points), and age 18 to 65 years. Exclusion: patients in unstable or critical condition. Patients were graded as stable or borderline (increased risk of systemic complications). : Incidence of acute lung injuries. Ten European Centers, 165 patients, mean age 32.7 +/- 11.7 years. Group intramedullary nailing, n = 94; group external fixation, n = 71. Preoperatively, 121 patients were stable and 44 patients were in borderline condition. After adjusting for differences in initial injury severity between the 2 treatment groups, the odds of developing acute lung injury were 6.69 times greater in borderline patients who underwent intramedullary nailing in comparison with those who underwent external fixation, P < 0.05. Intramedullary stabilization of the femur fracture can affect the outcome in patients with multiple injuries. In stable patients, primary femoral nailing is associated with shorter ventilation time. In borderline patients, it is associated with a higher incidence of lung dysfunctions when compared with those who underwent external fixation and later conversion to intermedullary nail. Therefore, the preoperative condition should be when deciding on the type of initial fixation to perform in patients with multiple blunt injuries.

Femoral shaft fractures in patients with severe cerebral palsy fixed with humeral nails: A report of two cases and a new technique of surgical stabilization

Fractures are not uncommon in individuals with severecerebralpalsy (CP)becausetheirbonesusually have very low mineral density, deformity and developmentaldisability.Thesefracturesareoftentreated non-operatively but sometimes result inmal-union or non-union of the fracture. Some femoral fractures require open reduction and internal fixation, but there have been few papers discussing suitable implants for difficult fractures in these patients.

１５歳〜２０歳における大腿骨骨幹部骨折に対する髄内釘の治療経験

It is sometimes difficult to choose the fixator of femoral shaft fractures in patients between the ages of 15 and 20, because of a remaining epiphyseal line or medullary space narrowing. We report a study on the surgical treatment of femoral shaft fractures with intramedullary nail in this age range. Forty-one femoral shaft fractures treated by intramedullary nail, which could be surveyed for over 3 months out of the 46 femoral shaft fractures we experienced for 10 years (from 1992 to 2002), were studied. Thirty-four patients were male and 7 female, with the mean age at surgery of 17.8 years. Thirteen patients were 1/3 proximal fracture, 24 were 1/3 middle fractures, and 4 were 1/3 distal fractures. Twenty-five fractures were type A, 11 were type B, and 5 were type C separated by AO’s classification. Thirty-four fractures were operated with Russell-Taylor nails (2 were reconstruction nails), and 5 were with Ender nails. Follow-up periods ranged from 3 months to 34.5 months (average: 17.5 months). We researched their range of motion, the period until bone union, and so on, separating AO’s classification, and their fixator. The average period of bone union was 23.9 weeks, and all patients were cured by bone union. Four patients underwent dynamization.

Bilateral retrograde femoral nailing in an obese patient

Intramedullary nailing of femoral shaft fractures in patients with a high body weight is dicult because of problems associated with the introduction of the nail through the massive hip region. This case report deals with a young obese male with bilateral femoral shaft fractures. Extensive hematoma of both thighs and preexisting adiposity of both hip areas precluded antegrade nail insertion and a retrograde approach was chosen.

Conservative treatment of femoral shaft fractures in patients with total hip arthroplasty

Over a period of 20 years, 34 patients with a total hip arthroplasty were treated conservatively for a femoral shaft fracture. Thirty-five fractures were treated by traction followed by cast-brace or by cast-brace alone. Sound healing was obtained in 33 fractures. Problems were angular malalignment jeopardizing revision surgery in cases of loosening, long hospitalization, and a considerable complication rate. As a consequence, the authors no longer recommend conservative treatment as the first choice for these difficult fractures.