Pediatric Femoral Fractures Research Articles

Functional and radiological results of the surgical treatment of pediatric femoral neck fractures

Aim: Our aim in this study was to evaluate the demographic data on femoral neck fractures, postoperative complications, and functional and radiological results following its surgical treatment in the pediatric age group. Pediatric femoral neck fractures often occur after high-energy trauma and seen rarely.Methods: Twenty-six patients who underwent surgery after the diagnosis of femoral neck fracture in our clinic between 2012 and 2019 were examined. Demographic data, trauma mechanism, accompanying injuries, and postoperative complications of the patients were recorded from our registry system. Functional radiological evaluation was performed using Ratliff criteria.Results: The mean age of the participants in the study was 11.11 (3–16) year, and the mean follow-up time was 29.34 (12-60) months. According to Ratliff criteria, 18 patients (69.2%) achieved good, 6 patients achieved (23.1%) moderate, and 2 patients achieved (7.7%) poor results after surgery. Avascular necrosis was observed in 5 patients (19.2%) in total. Avascular necrosis did not occur in 10 patients who underwent surgery within first 6 hours. Avascular necrosis occurred in 5 (31.25%) out of 11 patients who underwent surgery after 6 hours. This result was statistically significant (p = 0.049). Of the 5 patients with avascular necrosis, 3 were female and 2 were male. The clinical and radiological results were evaluated according to the Ratliff criteria, and the results were found to be worse in females than in men. There was a statistically significant difference between the genders (p=0.029).Conclusion: Although femoral neck fractures are rare injuries in the pediatric age group, they are important due to the high risk of complications. The most important complication is avascular necrosis. Results are better males than in females. The results of surgical treatments aimed at anatomical reduction in the shortest possible time are satisfactory.

Impact on Family Functioning of Immediate Spica Casting for Pediatric Femur Fractures: An Ecological Study

Background: Traditional treatment for femoral shaft fractures in children aged 6 months to 6 years old is closed reduction and immediate spica casting. Pediatric femur fracture and spica cast treatment place unique burdens and stresses on the family. The purpose of this study was to evaluate the impact on the family from an ecological perspective of immediate spica casting for femoral shaft fractures in children using appropriate validated family functioning questionnaires. Methods: Families of 46 children aged 0.5 to 6.0 years old who were treated with immediate one and a half leg spica casting for femur fracture were surveyed using the Impact on Family Score (IFS), the Feetham Family Functioning Survey (FFFS), and qualitative comments. The impact of spica cast treatment on family functioning was determined for multiple domains and compared between subgroups. Results: Spica cast treatment for pediatric femur fractures had major impacts on the families of 46 children with a mean age of 2.9 years (range, 0.5–6.0 years) across multiple domains. The IFS demonstrated greater impact of spica cast treatment than treatment for children with major chronic illnesses. There was a greater impact on family for school age children (5–6 years old) compared to younger children (0.5–4 years old) for the overall IFS score, the general impact IFS domain, the disruption of family IFS domain, the coping IFS domain, and the overall FFFS discrepancy score. There was greater impact on family for children of working parent(s) compared to children with a parent at home for the overall IFS score, the general impact IFS domain, the disruption of family IFS domain, the coping IFS domain, the financial impact IFS domain, and the overall FFFS discrepancy score. There was no correlation between duration of time spent in hip spica cast with either IFS or FFFS discrepancy score. Conclusions: Pediatric femur fracture and spica cast treatment can have a major impact on family functioning, particularly in school age children and in families with working parents. Providers should consider the impact of treatment on family functioning and recognize that each patient and family unit require education and varying levels of support. Education to families of children undergoing spica cast treatment may help prepare them for the various ways their household dynamics could be affected throughout their child’s treatment.

Хірургічне лікування переломів тіла стегнової кістки в дітей та підлітків: ранні та віддалені результати

Pediatric femoral fractures is a topical issue of modern pediatric traumatology. They are among the most common fractures of long bones and are the most common orthopaedic injury requiring hospitalization. Treatment of femur fractures in children vary on the basis of the mechanism of injury, the patient’s age, weight, the fracture pattern, family circumstances, and cost. Non-operative management plays a role in some cases but operative fixation as it allows early mobilisation and shorter hospital stays. Purpose – to analyze our experience in surgical treatment pediatric femoral shaft fractures with different methods, early and late complication. Materials and methods. For the period from 2008 to 2019, 148 children with acute femur shaft fractures were treated in our department, pathological fractures were exclude. They were divided according to surgical approach into 4 groups: elastic intramedullary nail (ESIN) – 109 patients (113 femurs), intramedullary locking nail (IMN) – 27 patients (27 femurs), external fixator – 8 patients (8 femurs), and plating – 4 (4 femurs). Comparisons were made between 2 groups: intramedullary nailing with closed reduction (124 femurs) and open reduction (16 femurs), of which 102 male and 38 female; aged of patients was 6–17 years. Hospitalization time of – up to 24 hours – 92 (63 boys, 29 girls), 1–7 days – 56 (39 boys, 17 girls). The indication for the use of flexible intramedullary rods was the age of children under 14 years of age with a weight of no more than 50 kg; in children of the older age group, an intramedullary blocked rod with an insertion point through the apex of the greater trochanter was used. Results. Flexible intramedullary nailing was used in 109 (74%) by standard retrograde technique 102 patients (106 femurs) and antegrade technique 7 patients (7 femurs), closed reduction was done in 121 patients (124 femur), open reduction in 15 patients (16 femurs). A blocking intramedullary rod was used in 27 children of the older age group, which amounted to 18%. Aseptic necrosis of the femoral head or changes in the proximal femur was not observed in any patient. There were only 4 (3%) children in the plating group, one case had refracture, 2 cases had infection. In all patients, except one with polytrauma, complete consolidation of the fracture was observed. The duration of the operation, the time of stay in the hospital, the amount of blood loss and postoperative pain were significantly lower in the group with closed reduction technique than in the group where the open reduction of the fragments was used. The dependence of the results of treatment and the beginning of the axial load on the affected limb on the duration of surgery was not found. Most common early complication was soft tissue irritation at the nail entry site (32 patients – 18 boys, 14 girls). Varus deformity of the femur was observed in 9 children (5 boys, 4 girls), in one patient this deformity was combined with limb shortening, valgus deformity was found in 3 patients (2 boys, 1 girl), rotational deformity in 2 patients (2 girls). According to Flynn’s criteria, only 2 patients had a poor result. Conclusions. Titanium elastic nailing is a relatively simple, minimally invasive method of surgical treatment of fractures of the shaft femur in children and adolescents with high rates of good and excellent results. For children of the older age group use of an intramedullary blocked nail is a safe procedure without the development of any changes in the proximal femur. The research was carried out in accordance with the principles of the Helsinki declaration. The study protocol was approved by the Local ethics committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interest was declared by the authors. Key words: femur shaft fracture, elastic intramedullary nail, swivel rod, surgical treatment.

Effect of the Number, Size, and Location of Cannulated Screws on the Incidence of Avascular Necrosis of the Femoral Head in Pediatric Femoral Neck Fractures: A Review of 153 Cases.

The correlation between the number, size, and location of cannulated screws and the incidence of avascular necrosis (AVN) in children with femoral neck fractures treated surgically is uncertain. We retrospectively reviewed 153 children (mean age: 10.6±3.7 y) with femoral neck fractures treated by internal fixation with 2 (n=112) or 3 (n=41) cannulated screws. The severity of initial displacement was divided into incomplete (type I) and complete (type II, angulation <50 degrees; type III, angulation >50 degrees) fractures. The diameter of the screw was measured and recorded as a percentage of the femoral neck width. The distance (D) between the mid-point of each screw at the base (B) of the femoral neck and at the tip (T) of each screw and the superior and anterior cortices of the femoral neck, respectively, were measured on anteroposterior (AP) and lateral (L) radiographs. Values were expressed as the ratio between the measured distance and the width of the femoral neck (BDAP%, TDAP%, BDL%, and TDL%). The correlation between the number, size, and location of the screws and AVN was analyzed. Patients with type II of initial displacement treated with 2 cannulated screws had a lower AVN rate (21.4%) than those treated with 3 screws (44.8%) (P=0.027). Screw diameter (19%) in patients with AVN was larger than (17%) in patients without AVN (P<0.001); patients with AVN had a lower BDAP% (48.6%) than those without AVN (56.4%) (P<0.001). Screw size and BDAP% were risk factors for AVN (P<0.05). Further, screw diameter >16.5% and BDAP% <51.6% of the femoral neck width were the cutoff values for an increased AVN rate (P<0.05). Patients treated with 2 cannulated screws showed a lower rate of AVN than patients treated with 3 screws. Screws of larger size and screws closer to the piriformis fossa on AP radiographs increased the risk of AVN in children with femoral neck fractures treated surgically. Level III.

Defining length stability in paediatric femoral shaft fractures treated with titanium elastic nails.

IntroductionOptimal paediatric femoral shaft fracture patterns or lengths amenable to titanium elastic nail stabilization have not been well defined. The purpose of this study is to identify radiographic parameters predictive of treatment failure with flexible intramedullary nails based upon fracture morphology.MethodsA retrospective review was performed of all femoral shaft fractures treated with flexible intramedullary nails over a five-year period. All patients with at least six weeks of postoperative radiographic imaging were included. Fracture characteristics included location, pattern, length, obliquity, angulation, translation and shortening. Postoperative radiographs were reviewed to determine shortening and angulation.ResultsThere were 58 patients with 60 femoral shaft fractures stabilized with titanium nails, with 46 healing within acceptable parameters and 14 considered malunions. Six of the 14 malunions developed complications requiring early unplanned intervention. No patients in the treatment success group had a complication. Between the treatment success and failure groups, fracture pattern, location, length, obliquity, angulation, translation or shortening were not statistically different. Mean nail canal fill was significantly lower in the failure group (0.72 versus 0.81; p = 0.0146), with a receiver operating characteristic curve identifying canal fill 76% as the optimal threshold.ConclusionThis is the first study to measure the length and obliquity of paediatric femoral shaft fractures and to determine their relationship to radiographic alignment after healing. None of the preoperative fracture characteristics were predictive of malalignment or shortening. We recommend the use of larger nail sizes in the treatment of paediatric femoral shaft fractures, especially if there is concern for residual instability.Level of evidenceIV

The Feasibility of Utilizing Malunion Criteria to Limit Radiographs After Spica Casting for Pediatric Femur Fractures.

There are no existing guidelines regarding the timing or frequency of postoperative radiographs following spica casting for pediatric femur fractures. The purpose of this study was to evaluate established femoral malunion criteria as a potential screening tool to limit postoperative radiographs by identifying patients at risk for unacceptable alignment in the early treatment period. A retrospective chart review was conducted for pediatric femoral shaft fractures presenting to a tertiary pediatric referral hospital from 2012 to 2017. Pediatric femur malunion criteria were applied to radiographs at initial presentation, first follow-up visit, and final follow-up visit. The primary outcome was a change in management based on radiographic findings in the early postoperative period. Secondary outcomes included radiographic measures, number of follow-up visits, and complications. Of 449 consecutive pediatric femur fractures treated at our center, 149 patients aged 1 to 4 years (mean age: 2.5±1.6 y) met inclusion criteria. At initial presentation, 36.9% (55/149) of patients met malunion criteria. Only 4.0% (6/149) of patients had a change in management following initial closed reduction and spica cast application due to radiographic findings at subsequent follow-up. Of these patients, 67% (4/6) were identified on preoperative imaging, and 83.3% (5/6) were identified by their first clinic appointment. Four of the 149 patients were converted to definitive surgical fixation, and 2 patients required cast wedging due to either unacceptable fracture shortening or coronal/sagittal angulation. Routine early postoperative radiographs may not be necessary for all pediatric femur fractures managed with closed reduction and spica casting. The value of this study is that it is the first to demonstrate the feasibility of limiting postoperative radiographs using a preoperative screening tool. However, the established femoral malunion criteria utilized in this study were limited in their predictive value, and further work is necessary to improve the sensitivity and specificity before widespread clinical application. Level IV.

A review of pediatric femoral fracture patterns, surgical managements, and outcomes

&lt;p class="abstract"&gt;&lt;strong&gt;Background: &lt;/strong&gt;Femoral fractures are the most common pediatric orthopedic fractures that require hospitalization. The non-accidental injury should be suspected in early infancy and non-ambulatory children. Treatment of pediatric femoral fractures is widely variable and depends on intrinsic and extrinsic factors. This study presents pediatric femoral fracture epidemiology and outcomes and reviews the literature regarding best practices in pediatric femoral fractures.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This retrospective study reviewed the clinical and radiological records of forty-sevens femur fractures in the pediatric age group from September 2020 until June 2021 in Prince Rashid bin AL Hassan Military Hospital in Jordan.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Males form 80.9% of patients. The mean age for the patients was equal to 6.70 years (±3.91). Falling is responsible for the majority of the injury. The middle femur shaft was fractured in 46.8%, and the pathological fracture was found in 17% of patients. Non-operative treatment by cast represents 42.6%. All fractures were healed at 7.90 weeks (±2.37).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Pediatric femur fracture lacks standardized treatment. Nevertheless, most fractures healed with satisfactory results. Younger age groups are more likely to be treated non-operatively. Non-surgical treatment is more prone to shortening, angulation, and later return to weight-bearing and activity. Children older than eight years treated by plating demonstrated faster healing, return to full weight-bearing, and lower complication rate. &lt;/p&gt;

Flexible Intramedullary Nail Fixation With Supplemental External Fixator for Unstable Pediatric Femur Fractures: A Case Series

Introduction: Flexible intramedullary nail fixation (FIN) has become the preferred mode of treatment for femur fractures in elementary school aged children. One clear limitation of FIN is the inability to control length unstable femur fractures. This case series evaluates radiographic union rates, fracture alignment, and postoperative complications for a novel technique of FIN and adjunct external fixation in length unstable femur fractures. Materials and Methods: A retrospective chart review was performed using current procedural terminology coding to identify 10 pediatric femur fractures utilizing flexible nail fixation with supplemental external fixation in length unstable femur fractures. Electronic medical records were used to obtain demographic information and length of operative time. A picture archiving and communication system was utilized to review radiographs. Results: Combined FIN fixation and supplemental external fixation were used in ten pediatric patients with length unstable femur fractures. The average age at time of injury was 6.4 years (range: 3 to 8 years). The average duration of external fixation was 30 days with no pin site complications including infection or refracture. Average time to union was 54 days with no radiographic loss of reduction. There were no documented intraoperative or postoperative complications. Conclusions: The cases reviewed in this study support that in addition to FIN fixation for unstable pediatric femur fractures, a supplemental external fixator provides a viable option with all fractures obtaining union, acceptable alignment, no loss of reduction, and no postoperative complications. This technique may provide another tool in the orthopedist armamentarium and possibly as an alternative to submuscular plating.

A study of titanium elastic nailing system in paediatric femur fractures

Aim: To analyse impact of Titanium Elastic Nailing System in Paediatric Femur Fractures. Material and Methods: In this study, 35 cases of femoral fractures were studied, in the Department of Orthopaedic at Pad. Dr. D. Y. Patil Hospital Nerul, Navi Mumbai, from June

Titanium elastic nails versus plating in paediatric femoral fractures: A prospective randomized study

Background: Femoral shaft fractures are a common paediatric injury that can be treated in a variety of ways. We conduct a randomised trial to compare two operational strategies.Material and methods: From 2019 to 2021, we treat 26 patients with fracture shaft femur.The patients ranged in age from 4 to 12 years old, with 15 boys and 11 girls. 12 patients had left-sided injuries, whereas 14 had right-sided injuries. The first group of 13 patients (8 males and 5 females) were treated with titanium elastic nails (TENS), while the second group of 13 patients (7 males and 6 females) were treated with open reduction and internal fixation utilising thin plates. The clinical and radiological findings were evaluated using the Flynn etal (2001) scoring system at regular intervals (2 weeks, 6 weeks, 3 months, 6 months, and 1 year). Results: Eight patients in the TENS group had outstanding results, while five others had good results with minor problems. With an average of 8.4 weeks, the union was completed (rang 6 - 12 weeks). Seven patients in the plating group had great results, four had acceptable results with mild problems, and two patients had poor results, including re-fracture after metal removal, severe infection that healed after later metal removal and debridement, and severe infection reaching the bone. Union took an average of 9.6 weeks, ranging from 6 to 14 weeks. Conclusion: Pediatric femoral fractures can be treated using TENS, which is a simple, dependable, successful, and less invasive approach.

Analysis of pediatric diaphyseal femoral fracture treated with titanium elastic nailing system

With many modalities available in literature to treat a pediatric femur diaphyseal fracture, it often creates a debate amongst the orthopedicians to choose a treatment of choice. The frequency of such fractures is increasing over the years due to increasing road traffic accidents. Until recently the conservative management was the preferred method to treat such injuries, however because of advantages such as early mobilization, reduced hospital stay, reduced loss of school days, less psychological impact and better nursing care, Titanium elastic nailing system (TENS) has gained the popularity over last two decades. In north eastern region of India to the best of our knowledge, no such study has been done to assess the functional outcome of TENS in pediatric femur diaphyseal fracture in age group of 6-11 years. Hence we retrospectively analysed the result of pediatric femoral diaphyseal fractures in 32 children (23 boys and 9 girls) in the age group of 6-11 years stabilized with titanium elastic nail (TEN).Results: Using Flynn criteria, outcome was excellent in 90.62% (n=29) children and satisfactory in 9.27% (n=3) children at the final follow up period of 6- 8 months after operation. Patients achieved union over a mean period of 8 weeks. Pin site irritation was found in 12.5% (n=4) patients initially which later subsided with physiotherapy at final follow up (6 months). No cases with superficial or deep infection were reported. No child reported any rotational or sagittal plane deformities.Conclusion: Titanium elastic nailing system provides an effective mode of treatment in pediatric femoral diaphyseal fracture in the age group of 6-11 years with advantages of early mobilization and union.

Analysis of the factors that are important in re-displacement in pediatric diaphyseal femur fractures treated with a spica cast

BackgroundThere is no detailed data on the factors affecting the re-displacement in pediatric femoral fractures treated with closed reduction and early spica casting. This study aimed to investigate the factors effective in re-displacement in pediatric diaphyseal femur fractures (PDFF) treated with spica casting. MethodsIn all, 151 displaced PDFF were evaluated retrospectively. Demographic data of the patients were evaluated. Type of fractures, anteroposterior and lateral angulations, amount of shortening, translation ratio, cast index (CI), gap index (GI), and three-point index (TPI) measurements were evaluated radiologically. Thigh flexion angle (TFA) and knee flexion angle (KFA) were measured. After casting, angulation of more than 10° in any plane and a shortening of more than 10 mm was accepted as re-displacement. Binary logistic regression analysis was used to evaluate the risk factors of re-displacement. Receiver operating characteristic analysis was performed for TFA and KFA. ResultsRe-displacement was detected in 40 patients (26.5%). Transverse type fracture (p = 0.001), TFA ˂71.4° (p <0.001), and KFA ˂52.6° (p = 0.002) were found to be statistically significant factors on re-displacement. It was determined that the combination of transverse femoral fracture and TFA ˂71.4° increased the probability of re-displacement by approximately 14 times. It has been observed that indices such as CI, GI, and TPI were not effective in predicting the risk of re-displacement. ConclusionWhen treating a PDFF with spica casting, one should be aware of re-displacement if the fracture type is transverse, TFA is ˂71.4°, and KFA is ˂52.6°. Level of evidenceLevel III, prognostic

Retrospective analysis of 35 pediatric femoral neck fractures.

Pediatric proximal femur fracture is extremely rare trauma comparing to other fractures. The proximal femur fracture is 1% of all pediatric fractures. The aim of current study is to compare the incidence of early complications and outcomes of pediatric proximal femur fractures regarding fracture types retrospectively. Our study includes 35 cases which are criticized by Delbet classification system, modalities of treatment, duration of waiting for surgery, duration of follow-up and also complications. Our inclusion criteria are age below 16years old, proximal femur fractures with no evidence of tumoral, romathologic and methabolic conditions. Age, sex and surgery type (open-closed) were noted, and the data were statistically assessed. Assessment of the final outcome was made at the last follow-up visit using the Ratliff's method. The mean of age of patients in our study is 9.5 ± 5.06years. The average follow-up was 25.6 ± 13.2months. 15 patients (42.9%) are type 2 Delbet fracture, 5 patients (14.2%) are Delbet type 3 and 15 patients (42.9%) are Delbet type 4 fracture. Using the Ratliff's method, 25 patients (71.4%) had satisfactory outcomes. Ten patients (28.6%) had unsatisfactory outcomes. The complications as AVN, coxa vara and premature closure of physis, non-union and postoperative infections have been detected in this study. AVN was seen in four (11.4%) patients. In addition, coxa vara was seen in six (17.2%) patients. Pediatric femoral neck fractures are extremely rare fractures and can be treated with low complication rates in cases with early treatment and anatomic reduction.

Safe transport of spica casted infants: Reducing the risk of traumatic injury in side impact collisions

BackgroundThere is limited data on transporting small children in hip spica casts used to treat pediatric femur fractures. Specific challenges include the fixed position of the body in the casted position and the increased size of the child due to cast thickness. Additionally, children less than 2 years old are recommended to be rear facing during transportation. This traveling position requires seats that are specifically designed to accommodate the small size of the child as well as accommodate the rear facing position. While seats able to accommodate casted children are available, it is unclear if they provide adequate protection in side impact collisions for rear facing spica casted infants. Therefore, the aim of this study was to evaluate traumatic injury metrics in a side impact collision model where a spica casted infant crash dummy was restrained in currently available car seats. MethodsTwo seats designed for spica casted children (R82 Quokka, Merritt Wallenberg) and two traditional car seats (Britax Emblem, Graco Sequel) able to accommodate a casted one-year-old crash test dummy were identified. Side impact collision testing was performed with the dummy positioned in the rear facing position and injury metrics recorded. ResultsTesting identified contact between the dummy's head and the door panel for a specialty spica car seat without protective side-wings for the head. All other seats contained side wings and prevented door-head contact. ConclusionsCasted children should be transported in a seat able to accommodate the cast and safely restrain them. Our results demonstrate the importance of side wing protection in any seat used to transport these children as side bolsters may help decrease the potential for head contact with the door and lower the risk of severe head injury.

Cystic Fibrosis with Paediatric Femoral Neck Stress Fracture: A Case Report and the Review of Literature

Cystic Fibrosis with Paediatric Femoral Neck Stress Fracture: A Case Report and the Review of Literature

Checklists in Femur Fractures: High Adherence After Implementation of Computer-based Pediatric Femur Guidelines.

Introduction:The American Academy of Orthopaedic Surgeons (AAOS) created an evidence-based clinical practice guideline for the care of pediatric diaphyseal femur fractures in 2010. Our institution implemented checklists based off these guidelines embedded in a standardized EMR order. The purpose of this study was to describe compliance with checklist completion and to assess safety improvement in a large urban pediatric hospital.Methods:Retrospective and prospective data were collected from 2 years before and 5 years after checklist implementation. This included the patient safety checklists from August 2011 through August 2016. Patients aged 0 to 18 years with a diaphyseal femur fracture were queried from the EMR and included in this study. Patient charts were reviewed for complications, including nerve injury, pressure sore, leg length discrepancy, loss of reduction, failure of fixation, nonunion, delayed union, and infection. Compliance rates were reported based on the AAOS clinical practice guidelines.Results:A total of 313 patients for the postchecklist period were reviewed in this study. Of 219 patients eligible for inclusion, 198 had checklists completed (group B). This group was compared with 100 patients with diaphyseal femur fractures from the period before implementation of the checklist (group A). We found no statistical difference in the number of patients with complications between groups (12% in both groups, P = 0.988). Postoperative checklists demonstrated that 89.9% of patients (178/198) received age-appropriate treatment consistent with the AAOS guideline recommendations after implementation of the checklist. Before the checklist implementation (group A), 94% (94/100) adhered to the guidelines.Conclusion:This study reveals high compliance rates with the AAOS evidence-based clinical practice guideline for the management of pediatric femur fractures. Implementing standardized checklists is possible by embedding them into the EMR. Implementation of checklists did not improve compliance or patient outcomes.

Risk Factors for Avascular Necrosis of the Femoral Head in Pediatric Femoral Neck Fractures

IntroductionA neck of femur fracture is a rare injury in the pediatric population and is of foremost importance, as it is associated with a high rate of complications. It usually occurs due to high-velocity trauma or a fall from a height. There is a scarcity of data on risk factors and their role in the prognostication of avascular necrosis. The purpose of the study was to retrospectively analyze the association of various risk factors with avascular necrosis (AVN) of the femoral head in patients with a neck of femur fracture in the pediatric age group.Material and methodsThe study included 21 (13 males and 8 females) pediatric patients with a neck of femur fracture treated at a university-level hospital. The patients were followed for a minimum of one year and the clinico-radiological outcome was analyzed using Ratliff criteria. The association of AVN with age, gender, side, fracture type, and injury with treatment delay, type of reduction, and type of internal fixation used was studied.ResultsThe mean age of the treated patients was 11 (±3.178) years (range=5-16 years). Avascular necrosis was seen in four patients and coxa vara occurred in two of them. A statistically significant association was seen between the Delbet fracture type and avascular necrosis, and three out of four cases of AVN were a Type I fracture (p-value=0.006). Three out of six patients having concomitant skeletal or other organ injuries developed AVN (p-value=0.022). The rate of AVN was higher in patients who were managed after 48 hours of initial injury but no statistically significant correlation was found (p-value=0.314). No statistically significant association with AVN was found between gender, age, type of reduction (closed/open), or the implant used (cannulated screws/k-wires).ConclusionsMultiple independent factors may have a role in the development of AVN of the femoral head in children. Prognostication should not be based on a single factor. Statistically significant results in this study have shown that the type of fracture and concomitant skeletal or other organ injuries are important risk factors and should be kept in mind. All independent risk factors must be noted and should be considered while prognosticating the outcome of a child with a neck of femur fracture.

Legg-Calvé-Perthes disease following Ender nail fixation of a pediatric femoral fracture.

Introduction and importanceLegg–Calvé–Perthes disease (LCPD) sometimes occur in children, however it is difficult to diagnose it at the early stage especially in the cases there are no complaints of symptoms. Femoral shaft fractures in children cause various complications such as leg-length discrepancy, nonunion and malunion, refracture, and osteonecrosis of the femoral head. We presented a rare case in which a pediatric patient developed LCPD after femoral shaft fracture.Case presentationA healthy 8-year-old boy sustained a left femoral diaphyseal fracture following a pedestrian car accident. Fixation was achieved using retrograde Ender nails; bone union was confirmed at 3 months postoperatively, and the Ender nails were removed at 8 months postoperatively without any problems. Unfortunately, the morphological change of the ipsilateral femoral head and subtle symptoms were missed until the femoral head collapsed. LCPD was successfully treated with intertrochanteric varus osteotomy, which achieved a good clinical result.Clinical discussionAlthough the reason for the ipsilateral LCPD after the femoral shaft fracture is unclear, this case highlights the need for close postoperative follow-up of pediatric femoral fractures resulting from high-energy trauma to prevent the misdiagnosis of this coincidental complication.ConclusionThis case report describes a missed ipsilateral LCPD after a femoral diaphyseal fracture caused by high-energy trauma. Close postoperative follow-up with a detailed assessment and vigilant interpretation of postoperative radiography is imperative to avoid delayed/missed diagnosis of conditions for which early management may provide better outcomes.

Intraoperative Burden of Flexible Intramedullary Nailing and Spica Casting for Femur Fractures in Young Children.

Spica casting (Spica) remains the widely accepted treatment of closed femoral shaft fractures in young children aged 6 months to 5 years. In some centers, there has been a recent trend towards surgical fixation of these fractures with flexible intramedullary nails (FINs). Despite numerous studies evaluating both Spica and FIN treatment of femoral shaft fractures, there remains a paucity of data regarding patient burden during the intraoperative period. The purpose of this study was to compare the intraoperative burden, defined as anesthetic exposure, fluoroscopic duration, and radiation load, between Spica and FIN treatment of femoral shaft fractures in young children. A retrospective chart review was conducted for pediatric femoral shaft fractures presenting to a tertiary pediatric referral hospital from 2012 to 2017. Comparison groups included pediatric femur fractures treated with Spica and those treated with FIN. Outcomes included anesthetic exposure, fluoroscopy duration, and radiation exposure. In addition, length of stay, clinic visits, and complications were recorded. Of 449 consecutive pediatric femur fractures treated at our center, 143 patients ages 2 to 6 years (mean age 3.8±1.4 y) met inclusion criteria. The Spica group contained 91 patients; FIN contained 52 patients. Mean anesthetic exposure was less for Spica compared with FIN [45.1 min, 95% confidence interval (CI): 38.0-52.3 vs. 90.7 min, 95% CI: 80.5-100.8 min; P<0.001]. On average, Spica procedures required less fluoroscopy time compared with FIN (15.4 s, 95% CI: 4.8-26.0 vs. 131.6 s, 95% CI: 117.6-145.6 s; P<0.001). Mean radiation load was less for Spica compared with FIN (1.6 mGy, 95% CI: 0.6-2.6 vs. 6.9 mGy, 95% CI: 5.7-8.1 mGy; P<0.001). There was no difference in length of hospital stay (P=0.831), follow-up visits (P=0.248), or complication rate (P=0.645) between Spica and FIN groups. The most common complication was skin irritation for Spica (18.7%) and symptomatic hardware for FIN (17.3%). The findings of this study suggest that pediatric patients with femoral shaft fractures experience an increased intraoperative burden when treated with FIN compared with Spica. Treatment with FIN was associated with increased exposure to anesthesia, fluoroscopic duration, and radiation load despite similar complication rates when compared with Spica. Level III.

Response to: Flexible Intramedullary Nailing of Femoral Shaft Fractures in Children Weighing ≥40 kg: A Systematic Review and Meta-Analysis.

BACKGROUND Pediatric femur fractures are commonly treated with flexible intramedullary nails (FIN). However, there is controversy regarding the effect of patient weight on outcomes and complications. The purpose of this meta-analysis was to review the literature and describe implant choice, analyze complication, and reoperation rates; as well as the report clinical and radiographic outcomes of FIN in pediatric patients weighing ≥40 kg with femoral shaft fractures. METHODS A systematic review was performed of all retrospective and prospective studies focusing on the use of FIN in heavy children in Medline, Cochrane, and Web of Science databases. Data extraction was performed and summarized using descriptive statistics. Quality assessment was performed using the Newcastle-Ottawa Scale. Meta-analysis was performed for complications using pooled data from included studies. RESULTS The initial search strategy yielded 177 references, and after exclusions, 5 studies were included. The majority of studies were retrospective, and the most commonly used implants in heavier patients were titanium FIN and stainless steel Enders FIN. There were higher rates of radiographic nonunion and malunion, complications, and reoperations for refracture; and nonunion in heavier children treated with FIN. Meta-analysis performed on 4 applicable studies showed the overall complication rate was higher in the heavier patients compared with lighter patients (30.6% vs. 11.1%) with a relative risk of 1.20 [95% confidence interval (CI), 1.02-1.41]. Heavier patients also had higher rates of major complications (relative risk, 1.32; 95% CI, 1.03-1.69) but similar minor complications (relative risk, 1.13; 95% CI, 0.90-1.41). CONCLUSIONS Heavier children have worse radiographic outcomes and higher complication rates with the use of FIN for femoral shaft fractures. Additional research is needed to determine the effect of FIN material on clinical outcomes in heavier children, and the relationship between weight and other known risk factors for poor outcome in FIN, such as length stability. LEVEL OF EVIDENCE Level III-systematic review of level-III studies.