Management Of Femoral Fractures Research Articles

Nerve blocks for initial pain management of femoral fractures in children

Children and adolescents with femoral fractures are almost always admitted to hospital. They invariably start their hospital experience in the Emergency Department, often requiring transfer to a specialist children's hospital. They require analgesia or anaesthesia so that radiographs can be obtained and for management of their fractures. The initial care process involves from two to six transfers from stretcher to stretcher/imaging/operating-suite table or hospital bed within the first few hours, so prompt pain relief is essential. Systemic analgesia can be provided orally or parenterally. Alternatively, a nerve block may be used where local anaesthetic is injected around a nerve to block sensation or freeze the involved area. To assess the effects (benefits and harms) of femoral nerve block (FNB) or fascia iliaca compartment block (FICB) for initial pain management of children with fractures of the femur (thigh bone) in the pre-hospital or in-hospital emergency setting, with or without systemic analgesia. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (11 January 2013), the Cochrane Central Register of Controlled Trials (2012 Issue 12), MEDLINE (1946 to January Week 1 2013), EMBASE (1980 to 2013 Week 01), Google Scholar (31 January 2013) and trial registries (31 January 2013). We handsearched recent issues of specialist journals and references of relevant articles. Randomised and quasi-randomised controlled trials assessing the effects of FNB or FICBfor initial pain management compared with systemic opiates in children (aged under 18 years) with fractures of the femur receiving pre-hospital or in hospital emergency care. Primary outcomes included failure of analgesia at 30 minutes, pain levels during procedures and transfers (e.g. to a stretcher or hospital ward) for up to eight hours, and adverse effects. Two review authors independently extracted data using a pre-piloted form. Two authors independently assessed the risk of bias for the included study and assessed quality of the evidence for each outcome using the GRADE approach; i.e. as very low, low, moderate or high. Meta-analysis of results was not possible as we found only one trial that could be included in the review. We included one randomised trial of 55 children aged between 16 months to 15 years. It compared anatomically-guided FICB versus systemic analgesia with intravenous morphine sulphate. The small sample size and the high risk of bias relating to lack of blinding resulted in a low quality rating for all outcomes.Overall, the trial provided low quality evidence for better pain management in the FICB group. Fewer children in the FICB group had analgesia failure at 30 minutes than in the morphine group (2/26 (8%) versus 8/28 (29%); risk ratio (RR) 0.33, 95% confidence interval (CI) 0.09 to 1.20; P value 0.09). The trial did not report on pain during procedures or transfers, or application of analgesia. The trial provided low quality evidence that FICB has a better safety profile than morphine, with only four (15%) reports of redness and pain at the injection site, and no reports of the type of adverse effects of systematic analgesia that occurred in the morphine group, such as respiratory depression (six cases (21%)) and vomiting (four cases (14%)). No long-term adverse events were reported for either intervention. Clinically significant pain relief was achieved in both groups at five minutes; with limited evidence of greater initial pain relief in the FICB group. Based on an inspection of graphically-presented data, at least 46% (12/26) of children in the FICB group had no supplementary medication (mainly analgesia) for the six hours of the study, while only 5% (1 or 2/28) of children in the intravenous morphine group went without additional analgesia. There was insufficient evidence to determine whether child or parental satisfaction with the method of analgesia favoured either method. Resource use was not measured. Low quality evidence from one small trial suggests that FICB provides better and longer lasting pain relief with fewer adverse events than intravenous opioids for femur fractures in children. Well conducted and reported randomised trials that compare nerve blocks (both FNB and FICB) with systemic analgesia and that use validated pain scores are needed.

Femoral fractures in children

Femoral fractures in children are the commonest children's fracture requiring hospitalization. They consume disproportionate amounts of healthcare resource. Advances in operative management have resulted in improved clinical and health economic outcomes. This article describes 21st-century management of femoral fractures concentrating on recent advances. There is a clear trend to increased operative management in all femoral fractures with improved outcomes in the proximal femur and shaft. Crucially, advances in the treatment of both have led to a reduction in the rate of avascular necrosis of the femoral head. Units treating paediatric fractures need access to specialist surgeons and equipment to treat the full range of femoral fractures and improve outcomes.

A38 Audit and management of femoral fractures in an orthopaedic department of a prefectural general hospital

A38 Audit and management of femoral fractures in an orthopaedic department of a prefectural general hospital

Management of Femoral Fractures in Dogs with Unilateral Semicircular External Skeletal Fixators

To report use of semicircular external skeletal fixators (ESF) for management of femoral fractures in dogs. Prospective clinical study. Dogs (n=16) with femoral fractures (n=18). A semicircular ESF system composed of 6-hole 45° or 5-hole 40° carbon-fiber arches, 6 mm threaded rods, half pin fixation bolts, 6 mm nuts, and negative profile end-threaded half pins were used for open repair of femoral fractures. ESF configuration, complications, limb use, fixator removal time, and functional outcomes were evaluated. Outcome was graded as excellent, good, fair, or poor. Seventeen fractures with sufficient follow-up healed. Eight dogs started using the limb immediately after waking up from anesthesia whereas initial limb use was 1-4 days after repair in the other dogs. Time to fixator removal ranged from 28 to 63 days (mean, 38 days). Functional outcome was excellent in 13 cases, good in 4, and poor in 1 nonunion. Semicircular ESF combined with open surgical reduction can be used to successfully repair metaphyseal and diaphyseal femoral fractures in young growing dogs.

Traction Table-related Complications in Orthopaedic Surgery

Traction tables are used in numerous procedures about the hip and femur, including fracture fixation, hip arthroscopy, and less invasive arthroplasty. The use of a traction table is not without risks, however, and significant complications have been described, including injury to the perineal integument and soft tissues, neurologic impairment, and iatrogenic compartment syndrome of the well leg. The orthopaedic surgeon who uses a traction table for the surgical management of femur fracture must be familiar with the associated potential dangers and risks and must develop a plan to avoid traction table-associated complications, such as use of a radiolucent flat-top operating table for obese patients, adequate patient positioning, and the minimum possible surgical time.

Decreased Complications of Pediatric Femur Fractures With a Change in Management

Elastic intramedullary nails are commonly the preferred treatment option for operative stabilization of pediatric diaphyseal femur fractures. Increased complication rates have been reported in unstable fractures and older patients treated with TENs (titanium elastic nails). The reported complications have led to a change in management at our institution: limiting the use of TENs and using submuscular plating and trochanteric entry nails as alternatives. The purpose of this study is to analyze whether this change in management has improved outcomes defined by a decrease in complications between 2 time periods. This retrospective study compared 2 cohorts of femur fractures: those treated from January 2001 to January 2003 versus those treated from January 2003 to December 2006. Patient's age, weight, fracture type (stable or unstable), operative fixation technique, and complications were compared. Outcomes were measured by major or minor complications that occurred after operative treatment. Period I consisted of 46 patients and Period II of 95 patients. There was a significant decrease in TEN use in unstable fractures in Period II versus Period I. Submuscular plating increased from 9% in Period I to 28% in Period II. All complications decreased from 52% in Period I to 23% in Period II. Major complications decreased from 22% to 5%, and minor complications decreased from 30% to 18%. Complications in unstable fractures decreased from 57% to 26% and in stable fractures from 48% to 22%. Outcomes of pediatric femur fractures are improved with limiting the use of TENs to stable fractures. Complications resulting from unstable femur fracture management have decreased with other methods of stabilization such as submuscular plating or trochanteric entry nails.

Femoral Fractures in Adolescents: A Comparison of Four Methods of Fixation

The optimal management of femoral fractures in adolescents is controversial. This study was performed to compare the results and complications of four methods of fixation and to determine the factors related to those complications. We conducted a retrospective cohort study of 194 diaphyseal femoral fractures in 189 children and adolescents treated with elastic stable intramedullary nail fixation, external fixation, rigid intramedullary nail fixation, or plate fixation. After adjustment for age, weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminution, treatment outcomes were compared in terms of the length of the hospital stay, time to union, and complication rates, including loss of reduction requiring a reoperation, malunion, nonunion, refracture, infection, and the need for a reoperation other than routine hardware removal. The mean age of the patients was 13.2 years, and their mean weight was 49.5 kg. There was a loss of reduction of two of 105 fractures treated with elastic nail fixation and ten of thirty-three treated with external fixation (p < 0.001). At the time of final follow-up, five patients (two treated with external fixation and one in each of the other groups) had >or=2.0 cm of shortening. Eight of the 104 patients (105 fractures) treated with elastic nail fixation underwent a reoperation (two each because of loss of reduction, refracture, the need for trimming or advancement of the nail, and delayed union or nonunion). Sixteen patients treated with external fixation required a reoperation (ten because of loss of reduction, one for replacement of a pin complicated by infection, one for débridement of the site of a deep infection, three because of refracture, and one for lengthening). One patient treated with a rigid intramedullary nail required débridement at the site of a deep infection, and one underwent removal of a prominent distal interlocking screw. One fracture treated with plate fixation required refixation following refractures. A multivariate analysis with adjustment for baseline differences showed external fixation to be associated with a 12.41-times (95% confidence interval = 2.26 to 68.31) greater risk of loss of reduction and/or malunion than elastic stable intramedullary nail fixation. External fixation was associated with the highest rate of complications in our series of adolescents treated for a femoral fracture. Although the other three methods yielded comparable outcomes, we cannot currently recommend one method of fixation for all adolescents with a femoral fracture. The choice of fixation will remain influenced by surgeon preference based on expertise and experience, patient and fracture characteristics, and patient and family preferences.

Management of femoral fractures in the burned extremity

Management of femoral fractures in the burned extremity

Management of Femur Fractures in Children Ages 6 to 12 Years Old

Management of Femur Fractures in Children Ages 6 to 12 Years Old

Protocol for a randomized controlled trial on risk adapted damage control orthopedic surgery of femur shaft fractures in multiple trauma patients

BackgroundFractures of the long bones and femur fractures in particular are common in multiple trauma patients, but the optimal management of femur fractures in these patients is not yet resolved. Although there is a trend towards the concept of "Damage Control Orthopedics" (DCO) in the management of multiple trauma patients with long bone fractures as reflected by a significant increase in primary external fixation of femur fractures, current literature is insufficient. Thus, in the era of "evidence-based medicine", there is the need for a more specific, clarifying trial.Methods/DesignThe trial is designed as a randomized controlled open-label multicenter study. Multiple trauma patients with femur shaft fractures and a calculated probability of death between 20 and 60% will be randomized to either temporary fracture fixation with fixateur externe and defined secondary definitive treatment (DCO) or primary reamed nailing (early total care). The primary objective is to reduce the extent of organ failure as measured by the maximum sepsis-related organ failure assessment (SOFA) score.DiscussionThe Damage Control Study is the first to evaluate the risk adapted damage control orthopedic surgery concept of femur shaft fractures in multiple trauma patients in a randomized controlled design. The trial investigates the differences in clinical outcome of two currently accepted different ways of treating multiple trauma patients with femoral shaft fractures. This study will help to answer the question whether the "early total care" or the „damage control” concept is associated with better outcome.Trial registrationCurrent Controlled Trials ISRCTN10321620

Management of femoral fractures complicated with fat embolism syndrome

脂肪栓塞综合征是指直径为10～40μm的血管内脂肪颗粒阻塞血管腔而引起一系列病理生理改变的临床综合征.脂肪栓塞综合征是创伤后发生的严重并发症之一,临床上常表现为呼吸困难和低氧血症、意识障碍、皮肤黏膜出血点和发热等,如患者得不到及时的诊断和治疗,可出现严重后果,甚至导致死亡[1].2003年1月至2007年12月,我科收治10例股骨骨折伴发脂肪栓塞综合征患者,回顾性研究其临床资料,对其诊断及治疗结果进行分析,总结如下。

Influence of air ambulance doctors on on-scene times, clinical interventions, decision-making and independent paramedic practice

Background:Critics of air ambulance doctors question their contribution and believe on-scene time is prolonged. Two helicopter emergency medical service (HEMS) models operate in the West Midlands, one with doctors and...

Management of femoral fracture in a patient with essential thrombocythemia treated with plateletpheresis and intramedullary rod fixation, followed by hydroxyurea: a case report

We describe the management of a patient with a femoral fracture who had asymptomatic essential thrombocythemia. When the diagnosis of essential thrombocythemia was made, the patient was treated with plateletpheresis to reduce the platelet count before intramedullary rod fixation of his fracture. His postoperative management included the examination of his peripheral blood as well as bone marrow, which confirmed that the cause of his elevated platelet count was due to JAK2 V617F mutation that is treated by hydroxyurea and aspirin after being discharged from the hospital.

External skeletal fixation of femoral shaft fractures in polytrauma patients

Polytrauma remains a major social, economic and medicine affliction. A successful surgical treatment of polytrauma patients requires an approach predicated on prioritizing injuries. An isolated femur fractures rarely poses any threat but in association with multiple injuries, this fracture assumes greater significance. The proper management of femur fractures in polytrauma can greatly reduce the mortality and morbidity. We present our results in the treatment of 24 femur shaft fracture in 22 polytrauma patients treated by Mitkovic external fixator in 5 year period (2000-2004) on Orthopeadic and Traumatology Clinic--Clinical Center Nis. The average of patients age was 32.8 years (ranging from 17 to 62). There were 11 (46%) closed and 13 (54%) open fractures. Eighteen fractures were treated by external fixation until union. The remaining six fractures were treated by conversion of the external fixation to internal fixation. Sixteen fractures (88.88%), in which the external fixation was the definitive method of treatment, healed completely. The average healing time was 6.29 (4-9) months. There were three pin-track infections (16.66%), one nonunion (5.55%) and only one deep infection (5.55%). The external fixation by the use of Mitkovic external fixator in the treatment of femur fractures is a safe procedure to achieve temporary rigid stabilisation in polytrauma patients before the subsequent internal fixation (damage control orthopaedics). The external fixation using Mitkovic external fixator can be definitive method of choice in treatment of open and comminutive femur fractures in polytrauma patients until union.

Paediatric femoral fractures: Factors influencing length of stay and readmission rate

This report describes factors influencing length of stay and unplanned readmissions within 30 days of discharge for children presenting with femoral fractures to Starship Hospital. The charts and radiographs of all children admitted with femoral shaft fractures between January 1998 and December 2002 were reviewed, excluding pathological fractures. The type of management, the length of stay and the unexpected readmission rate within 30 days were recorded. Ninety-three children with 95 femoral fractures were included in the study. Forty-six fractures were treated by application of immediate hip spica and 49 by other surgical methods (21 by external fixation, 20 by flexible intramedullary nailing and 8 by other methods). Patients with isolated femur fractures treated by either hip spica application or other operative fixation had median lengths of stay of 3 days (range 1-10 days) and 6 days (range 2-15 days), respectively. Patients with associated injuries, whose femur fractures were treated by either hip spica application or other operative fixation, had longer median lengths of stay of 5 days (3-15 days) and 17 days (5-70 days), respectively. Nine of the 93 children had an unplanned return to the operating theatre during their initial hospital stay, with increased length of stay in 5 as a result. A further 21 children were readmitted within 30 days of discharge with problems of loss of fracture alignment and cast damage in the hip spica group; pin-site infections in the external fixation group and pain around the distal nail insertion site in the flexible intramedullary nailing group. Despite these early problems, fracture alignment was satisfactory at union in 89 of the 95 fractures, with satisfactory remodelling in the remaining six fractures at follow-up. The presence of associated injuries was a key factor in the length of the initial hospital stay. However, the need for further operative interventions in the first hospital stay also increased the length of stay in some patients. Overall, the operative management of femoral fractures is resource intensive with a significant need for further minor operative intervention, regardless of the type of initial management.

Treatment of femoral shaft fractures in polytrauma patients using Mitkovic type internal fixator

Polytrauma remains a major social, economic and medicine affliction. Successful surgical treatment of polytrauma patient's requires an approach predicated on prioritizing injuries. An isoleted fractures rarely poses any threat but in association with multiple injuries, a fractures assumes greater significance. Proper management of femur fractures in po-lytrauma can gretly reduce the mortality and morbidity. In this work the results of the operative treatments of the femoral shaft fractures in polytrauma patients using Mitkovic type internal fixator (14 patients) and Kuntscher nail (9 patients) are compared. The average patients age was 28.43 years (range 16 to 61). Internal fixation using Mitkovic type internal fixator can be method of choose in treatment of femur fractures in polytrauma patient's. Its application is relatively simple. It doesn't damage the periosteal and meduullary bone vascularization, which favors osteosynthesis and provides considerable contribution in osteogensis.

Peri prosthetic femur fracture's management in octogenarians—What works?

Peri prosthetic femur fracture's management in octogenarians—What works?

Titanium Elastic Nailing of Pediatric Femur Fractures

In the last 3 decades, there has been a very strong trend for pediatric orthopedic traumatologists to use some form of fixation to mobilize the school-aged child with a femur fracture . Titanium elastic nailing of pediatric femur fractures is a widely adopted technique that has stood the test of time. Perhaps the most attractive features of this technique for pediatric femur fracture management are the low rate of serious complications and the relatively easy and safe learning curve for most surgeons. There are several pitfalls to the titanium elastic nail technique that should be emphasized. In multiple series, the most common problem is irritation caused by the nails at their entry site. To avoid this most common complication, the nail should not be bent away from the distal femur , and only 1 to 2 cm of nail should be left outside the cortex of the bone. It is essential to follow the principles that were outlined years ago by the French developers of elastic nailing. The nail entry site, nail size and nail length should be symmetric. The nails should be prebent so that they have good cortical contact at the fracture site, as this cortical contact is a key factor in stability. The nails should be used cautiously in length-unstable fractures and in patients older than 12 years of age or who are heavier than 50 kg.

Femoral Nerve Block for Pain Management of Femoral Fractures in the Emergency Department: Evidence Based Topic Review

Femoral Nerve Block for Pain Management of Femoral Fractures in the Emergency Department: Evidence Based Topic Review

Complications of Titanium Elastic Nails for Pediatric Femoral Shaft Fractures

Limited data exist about complications of titanium elastic nails (TNs) for femur fracture management in pediatric patients. Thirty-nine patients with 43 femoral shaft fractures were identified whose average age was 6.0 years. There were 21 complications (1 intraoperative, 20 postoperative) in 43 femur fractures (49%). There were two major postoperative complications: one septic arthritis after nail removal and one hypertrophic nonunion. Minor postoperative complications were pain at the nails in 13 extremities, nail erosion through the skin in 4, and one delayed union. There was an association between the prominence of TNs and nail pain or skin erosion. Fracture angulation and outcome were associated with the patient's weight and size of the nails implanted. Technical pitfalls exist with this implant and can be minimized by leaving less than 2.5 cm of nail out of the femur and by using the largest nail sizes possible.