Management Of Pediatric Femoral Fractures Research Articles

Variability in the Follow-up Management of Pediatric Femoral Fractures.

Variability in follow-up has previously been identified in orthopaedic trauma. Variability in follow-up for pediatric femur fractures has not previously been documented. The aim of this study was to document the variability in clinical and radiographic follow-up for pediatric femur fractures based on the fixation method and the treating surgeon. This retrospective case series identified isolated femoral fractures in patients younger than 18 years, treated by eight surgeons at a single center from 2010 to 2015. The total number and frequency of clinical visits, radiographic visits and discrete radiograph views, demographic data, fracture classification, treatment method, and presence of complications were extracted. Variability in follow-up was assessed through descriptive statistics and linear and Poisson regression models. One hundred sixty-four femoral fractures in 160 patients were included. Fractures were stratified by the treating surgeon. The mean length of follow-up ranged from 6.5 to 13.6 months. Complications increased follow-up time by mean 1.7 months (1.3 to 2.4). Patients who were treated with rigid locking nails were followed for the shortest amount of time, averaging 9.9 months, while traction followed by rigid locking nails averaged 24.4 (0.5 to 9.3) months of follow-up. Variation in the length of follow-up was identified and was associated with the fixation method and the treating surgeon. Few patients were followed long enough to definitively identify complications and sequelae known to occur after femur fractures such as femoral overgrowth or growth arrest. The results of this study indicate a need for additional study and consensus on an appropriate follow-up for pediatric femur fractures.

Elastic nail fixation versus plate fixation of paediatric femoral fractures in school age patients – A retrospective observational study

IntroductionThe management of paediatric femoral fractures continues to spark debate in published literature, with poor quality evidence guiding current guidelines on the optimum treatment in children. Many centres report excellent results for both elastic intramedullary nailing and plate fixation of diaphyseal femoral fractures. This study aimed to investigate the outcomes of femoral fractures treated with elastic nail fixation versus those treated with plate fixation in a tertiary children's trauma unit, and discuss the advantages and disadvantages of each technique. Materials and methodsA retrospective review of all femoral fractures undergoing fixation at a level one paeditric trauma and tertiary referral unit, between 1st April 2009 and 30th April 2017, was performed.Clinical notes and radiographs were reviewed to determine patient demographics and injury, operative and hospital stay data. Radiological union, defined as bridging callus present on at least three out of four cortices on orthogonal radiographs, was determined at 12 weeks. Outcomes were determined using the Flynn Criteria. Patients were followed up for a minimum of 2 years. Data was statistically analysed, and a p value < 0.05 was considered significant. ResultsThere were a total of 28 patients- 14 in each treatment group. Patients undergoing elastic nail fixation were significantly older than plate fixation (9.7 ± 1.9 Vs 7.7 ± 1.8; p = 0.008). A male preponderance was noted (21/28), with no difference between groups (10 Vs 11; p = 1.00). Plate fixation demonstrated a tendency towards shorter length of stay (6.3 ± 2.1 Vs 7.8 ± 3.0; p = 0.134), earlier radiological union at 12 weeks (14 Vs 10; p = 0.098), lower postoperative analgesia requirements (0.82 ± 0.45 Vs 1.12 ± 0.97; p = 0.200), and better outcomes, as determined by the Flynn criteria. ConclusionsIn the authors opinion, plate fixation is a safe, effective alternative to elastic nail fixation with equivocal outcomes as determined by the Flynn Criteria. Plate fixation may offer advantages in shorter length of stay, reduced postoperative pain and earlier weightbearing. Further large scale, prospective research is required to determine whether these are borne out in practice.

Titanium Elastic Nails Versus Spica Cast in Pediatric Femoral Shaft Fractures: A Systematic Review and Meta-analysis of 1012 Patients.

There is a general consensus on the management of femoral fractures in children younger than two years and adolescents older than sixteen years. The best treatment for patients younger than sixteen years of age is still debatable. Titanium Elastic Nails (TEN), is widely used with some evidence, nonetheless, we undertook a systematic meta-analysis to assess the efficacy of TEN compared to Spica cast for the management of femoral shaft fracture in children aged between 2 to 16 years old. A computer literature search of PubMed, Scopus, Web of Science, CINAHL and Cochrane Central was conducted using relevant keywords. We included clinical trials and observational studies that compared TEN versus Spica cast; Records were screened for eligible studies and data were extracted and synthesized using Review Manager version 5.3 for Windows. Our search found 573 unique articles. After screening the abstract and relevant full text, 12 studies with a total of 1012 patients were suitable for the final analysis. In terms terms of union (in weeks), the reported effect sizes favoured the TEN group in two included studies only. Moreover, the overall standardized mean difference in sagittal (SMD -0.48, 95% CI [-0.70 to -0.26], P<0.001) and coronal angulations (SMD -0.66, 95% CI [-1.00 to -0.31], P<0.001) favored TEN fixation in management of femoral fractures younger than 16 years. The reported length of hospital stay was not consistent across studies. The overall risk ratio of malalignment (RR=0.39, 95% CI [0.27 to 0.57], P<0.001) favored the TEN as well as walking independently. Based on our analysis, TEN treatment is superior to traction and hip spica for femoral fractures in patients younger than 16 years old. Based on our analysis we recommend the use of TEN fixation in management of pediatric femoral fractures in patients younger than 16 years.

A Prospective Cohort Study of the Therapeutic Patterns, Challenges and Outcomes of Paediatric Femoral Fractures in a Cameroonian Tertiary Center.

Background:Knowledge of the therapeutic patterns, challenges and outcomes of treatment of paediatric femoral fractures (PFF) helps to better choose the ideal therapeutic modality which is still controversial. However, this data is scarce in the sub-Saharan African literature.Objective:To determine the therapeutic patterns, treatment challenges and outcomes of treatment of PFF in a tertiary care centre in Cameroon.Method:We conducted a prospective cohort study of all consenting consecutive cases of femoral fractures in patients younger than 16 years managed between 2011 and 2015 at the surgical unit of Yaoundé University Teaching Hospital, Cameroon. We analysed demographic data, injury characteristics, fracture patterns, treatment details, therapeutic challenges and outcomes of treatment at 12 months using Flynn’s criteria.Results:We enrolled 30 femoral fractures from 29 children with mean age was 4.2 ± 3.3 years. The male gender, diaphyseal locations and spiral fracture lines were predominant. Main mechanisms of injury were accidental falls, road traffic accidents and game injuries. Fracture management entailed 12 tractions followed by casting, 10 casting alone, four closed reductions followed by casting, two cannulated screw fixations, one pin fixation and one external fixation. The mean duration of consolidation was 10.3 ± 3.9 weeks. The outcome was rated excellent in 28 cases. Limited resources precluded fluoroscopy use, proper anaesthetic management, early rehabilitation and patient-parent satisfaction.Conclusion:Conservative management of PFF yields a good outcome in our setting. However, an improvement in surgical, radiology and anaesthetic infrastructure is needed for optimal PFF care.

Submuscular Plate for Pediatric Femoral Fractures.

Management of pediatric femoral fractures is dependent on patient age and injury pattern. For length-stable femoral shaft fractures in school-age children (5 to 11 years of age), flexible intramedullary nailing (IMN) is a popular treatment method. However, for fracture patterns that are length-unstable or involve the proximal or distal third of the femur, flexible IMN has a higher rate of postoperative complications. Use of a submuscular bridge plate has been shown to be an effective alternative to IMN for these injuries. Because this long plate is inserted with a minimally invasive technique and indirect reduction, it acts as an internal type of "external fixator," thereby avoiding soft-tissue stripping at the fracture site and decreasing strain across the fracture site.Step 1: Position the patient supine on a radiolucent table with a bump under the ipsilateral hip.Step 2: Lay a 4.5-mm narrow stainless-steel plate over the injured thigh and use fluoroscopy to determine the appropriate length for this plate. Contour the plate as needed.Step 3: Make a lateral, longitudinal incision of 2 to 3 cm at the proximal or distal part of the femur through the iliotibial band. Elevate the vastus lateralis extraperiosteally from the femur using a Cobb elevator. Pass the plate through this plane proximally or distally while maintaining contact between the plate and the femur.Step 4: Adjust the plate position using fluoroscopy. Obtain fracture reduction using closed techniques and secure the plate temporarily with Kirschner wires through the most proximal and distal holes.Step 5: Place the first screw near the end of the plate under direct visualization. Place the second screw using a percutaneous technique and insert it immediately proximal or distal to the fracture site where the femur is farthest from the plate. The drilling and length measurement of this screw are fluoroscopically aided and will bring the plate down into contact with the femoral cortex.Step 6: Place the remaining screws in a similar fashion; 3 screws proximal and distal to the fracture site provide adequate stability. Locking screws or lag screws are typically not necessary in this construct. Obtain final radiographs to ensure appropriate reduction length, alignment, and rotation.Postoperatively, patients begin hip and knee range-of-motion exercises without immobilization. Touch-down weight-bearing with crutches is used until callus formation is seen on radiographs, usually in 6 to 8 weeks. The plate can be removed 6 months after the index surgery.

Clinical outcomes and complications of titanium versus stainless steel elastic nail in management of paediatric femoral fractures-a systematic review.

Femoral shaft fractures in children account for approximately 1.6% of all fractures. These fractures can be treated both operatively and non-operatively. Surgical fixation is more common in the age group above 6years. Elastic intramedullary nails have become the most popular surgical modality of treatment over the last few decades. However, there is continuous debate about which type of elastic nails (titanium and stainless steel) provides better clinical outcomes with less complication. The main purpose of this study was to systematically search for and critically appraise articles comparing clinical outcomes and complications of titanium elastic nail system (TENS) and stainless steel elastic nail system (SSENS) in management of femoral fractures in the paediatric age group. A comprehensive search of MEDLINE, EMBASE, and Cochrane library databases was performed using specific search terms and limits. Applying strict eligibility criteria, the identified studies were screened. Five studies were identified and reviewed. All of the identified studies were non-randomised comparative studies apart from one randomised controlled study. Studies provide contradictory evidence with regard to time to fracture union and time to full weight bearing. Only one study commented on time to nail removal and found that it is shorter in the TENS group. Two studies showed significantly higher rate of malunion in the TENS group, whereas the rest showed no difference. There was no difference in the rates of delayed union or infection between the two groups and no consistent difference in the rates of skin irritation. Three studies compared Flynn's outcome score and found no difference apart from one study which found better scores in the SSENS group. There is no consistent evidence to indicate the advantage of one type of elastic nails over the other in management of paediatric femoral shaft fractures; however, the overall trend is in favour of SSENS especially being cheaper than TENS. Critical appraisal of the studies identified significant methodological deficiencies, and further prospective randomised trials are recommended for more potent evidence.

To study the outcome of closed intramedullary flexible nailing in fracture shaft femur in children age more than 3 year and less than 13 year

Femoral shaft fractures account for 1.6% of all paediatric bony injuries. Spica casting remains the most popular accepted method for treatment of femoral shaft fracture in infants and toddlers. The aim of our study is to study the outcome of closed intramedullary flexible nailing in fracture shaft femur in children aged more than 3 years and less then 13 years. This is institutional based prospective study of 60 patients, aged 3 to 13 years, with fracture shaft of the femur were treated with retrograde flexible intramedullary (titanium elastic) nailing at Dr. Shankarrao Chavan Govt. Medical College Vishnupuri, Nanded. Statistical analysis done by chi-square test. In the present study, the final outcome was excellent in 40 (66.66%) cases, satisfactory in 10(33.33%) cases and there were no poor outcome cases. TENS is a simple, easy, rapid, reliable and effective method for management of paediatric femoral fractures between the age of 5 to 15 years, with shorter operative time, lesser blood loss, lesser radiation exposure, shorter hospital stay, and reasonable time to bone healing.

Titanium elastic nailing in pediatric femoral diaphyseal fractures

Background: The need for operative fixation of pediatric femoral fractures is increasingly being recognised in the present decade. The conventional traction and casting method for management of pediatric femoral fractures is giving way for the operative stabilisation of the fracture. Methods : Thirty five pediatric patients in age group 6-14 years with diaphyseal femoral fractures were stabilised with two titanium nails. Patients were followed up clinically and radiologically for two years. The final results were evaluated using the criteria of Flynn et al. Technical problems and complications associated with the procedure were also analysed. Results : Overall results observed were excellent in 25, satisfactory in 8 and poor in 2 patients. Hospital time averaged 12.30 days in the series. All the fractures healed with an average time to union of 9.6 (6-14.4) weeks. Return to school was early with an average of 7.8 weeks. The soft tissue discomfort near the knee produced by the nails ends was the most common problem encountered. Shortening was observed in three cases and restriction of knee flexion in 5 patients. There was no delayed union, infection or refractures. Per operative technical problems included failure of closed reduction in 2 cases and cork screwing of nails in one case. Conclusion : We believe that with proper operative technique and aftercare TENs may prove to be an ideal implant for pediatric femoral fracture fixation. The most of the complication associated with the procedure are infact features of inexact technique and can be eliminated by strictly adhering to the basic principles and technical aspects.