Pediatric Femoral Shaft Fractures Research Articles

A Comparative study of the results of conservative treatment versus closed titanium elastic nailing for fractures of shaft of femur in children

Background: The ideal treatment of femoral shaft fracture in children is defined as one that controls alignment and length, is comfortable for child and convenient for family and causes the least psychological impact possible.Aims and Objective: The current study was designed to evaluate outcomes prospectively in the first year following treatment of a diaphyseal femoral fracture in children between five and ten years of age treated randomly either by intramedullary titanium elastic nailing or by traction followed by spica cast.Materials and Methods: Out of 48 cases selected according to inclusion/exclusion criteria 6 patients were lost to follow up. Among the rest of 42 patients, 23 were treated by intramedullary titanium elastic nailing and the other 19 conservatively by surface traction. The patients were evaluated at the regular interval of 2, 4, 6 and 8th week post operatively and thereafter every month.Results: There was a significant difference (p< 0.001) in terms of mean hospital stay and mean weight bearing between the two study groups. The findings of outcome and maintenance of reduction, time taken for the evidence of union to appear, the range of movements, the time when weight bearing can be allowed, the functional return of the limb, the rate of complications and the number days of hospital stay were comparable to similar studies conducted earlier.Conclusion: The study concludes that closed pediatric femoral shaft fractures within the ages of 5-10 years can be treated successfully by any methods of traction followed by spica cast or intramedullary titanium elastic nailing. However, because of shorter immobilization period and earlier ambulation, internal fixation with titanium elastic nailing is recommended as the better choice to treat this fracture in school going children.Asian Journal of Medical Sciences Vol.8(4) 2017 32-37

Current Concepts in Paediatric Femoral Shaft Fractures.

Pediatric femoral shaft fractures account for less than 2% of all fractures in children. However, these are the most common pediatric fractures necessitating hospitalization and are associated with prolonged hospital stay, prolonged immobilization and impose a significant burden on the healthcare system as well as caregivers. In this paper, the authors present a comprehensive review of epidemiology, aetiology, classification and managemement options of pediatric femoral shaft fractures.

Titanium elastic nailing for paediatric femoral shaft fractures: a prospective descriptive study

<p class="abstract"><strong>Background:</strong> Femoral shaft fracture is the most common major paediatric orthopaedic fractures. For generations traction and casting was the standard treatment for all femoral shaft fractures in children. Over the past two decades the advantages of fixation and rapid mobilisation have been increasingly recognised. Aim: To assess the functional and clinical outcome after closed reduction and internal fixation with titanium elastic nail in diaphyseal femoral fractures between 5 to 16 years.</p><p class="abstract"><strong>Methods:</strong> The study was conducted in the Department of Orthopaedic Surgery, Regional Institute of Medical Sciences (RIMS), Imphal, Manipur, from September 2013 to April 2015. Thirty children (20 boys and 10 girls) in the age group of 5 to 16 years with recent femoral diaphyseal fractures were stabilised by titanium elastic nails [TENS]. Results were evaluated according to Flynn’s scoring criteria.<strong></strong></p><p class="abstract"><strong>Results:</strong> After 25 months of follow up all thirty patients were available for evaluation. Radiological union were achieved in a mean time of 11.5 weeks. Mean duration of hospital stay was 15.23 days. According to Flynn’s criteria of TENS outcome score results were excellent in 66.7% patients, Satisfactory in 30% patients, Poor in 3.3% patient. All patients had early return to school. Per operative technical problems included failure of closed reduction in 2 cases.</p><p><strong>Conclusions:</strong> Titanium elastic nailing is an effective treatment in diaphyseal fractures of femur in properly selected patients. </p>

Flexible intramedullary nails: the panacea for paediatric femoral shaft fractures

<p class="abstract"><strong>Background:</strong> Management of pediatric femoral shaft fractures continues to evolve with time with flexible intramedullary nailing being one of the options to treat a specific age group of children. Grey zone exists concerning the cost effectiveness and appropriate timing of nail removal in treating such fractures. The objective of the study was<strong> </strong>to evaluate the treatment outcome of fracture shaft of the femur in children in the age group of 5- 12 years with flexible intramedullary nail<span lang="EN-IN">.</span></p><p class="abstract"><strong>Methods:</strong> The study comprised of 30 consecutive cases of acute fractures of the femoral shaft in children of the age group of 5 to 12 years. Only closed fractures of the mid-diaphyseal region of the femur were included while supracondylar, subtrochanteric and pathological fractures were excluded. Flexible intramedullary nails of stainless steel (n=24) or titanium (n=6) were used for fixation of these fractures.<strong></strong></p><p class="abstract"><strong>Results:</strong> Evaluation of the results was done according to the criteria by Flynn et al. 21(70%) out of 30 patients had an excellent result and remaining 9 (30%) had a satisfactory result. All fractures united with a full range of motion at the hip and knee joint without any major complications<span lang="EN-IN">. </span></p><p class="abstract"><strong>Conclusions:</strong> <span lang="EN-IN">Intramedullary elastic nailing of simple diaphyseal femur fractures in children is an effective method with negligible complications. Treatment cost can be significantly lowered by using the much cheaper stainless steel flexible nails rather than the more expensive titanium nails.</span></p>

Pediatric Femoral Shaft Fractures: A Multicenter Review of the AAOS Clinical Practice Guidelines Before and After 2009.

To determine if the AAOS clinical practice guidelines (CPG) for the treatment of pediatric femoral shaft fractures (2009) changed treatment, we analyzed pediatric femoral shaft fractures at 4 high-volume, geographically separated, level-1 pediatric trauma centers over a 10-year period (2004 to 2013). Consecutive series of pediatric femoral shaft fractures (ages, birth to 18 y) treated at the 4 centers were reviewed. Treatment methods were analyzed by age and treatment method for each center and in aggregate. Of 2646 fractures, 1476 (55.8%) were treated nonoperatively and 1170 fractures operatively. Of the operative group, flexible intramedullary nails (IMN) were used for 568 patients (21.5%), locked intramedullary nails (LIMNs) for 309 (11.7%), and plating for 188 (7.1%). In total, 105 fractures were treated with external fixation or skeletal traction. Analysis before and after the CPG publication revealed a significant increase in the use of interlocked IMNs in patients younger than 11 years (0.5% before, 3.8% after; P<0.001). Over the same time period there was an increase in surgical management, regardless of technique, for patients younger than 5 years (6.4% before, 8.4% after; P=0.206). There were considerable differences in treatment among centers: 74% of fractures treated with plating were from a single center (center A), which also contributed 68% of patients younger than 5 years treated with plating; center B had the highest rate (41%) of flexible IMN in children younger than 5 years; center C had the highest rate (63%) of LIMN in children younger than 11 years; and center D treated the fewest patients outside the CPG guidelines. Following publication of the AAOS CPG, there was a significant increase in the use of LIMNs in patients younger than 11 years old and a trend toward surgical treatment in patients younger than 5 years. The considerable variability among centers in treatment methods and adherence to the CPG highlights the need for further outcome studies to better define optimal treatment methods and perhaps update the AAOS CPG guidelines. Level III-therapeutic.

Detection of Femoral Neck Fractures in Pediatric Patients With Femoral Shaft Fractures

Ipsilateral femoral neck fractures occur in 1% to 9% of adult trauma patients with femoral shaft fractures making dedicated imaging important. This is not as clear in children. Our purpose is to establish the incidence of ipsilateral femoral neck fractures in children with femoral shaft fractures and to provide recommendations regarding diagnostic imaging protocols. A retrospective analysis of medical records was performed for pediatric patients (below 18 y) with femoral shaft fractures seen at our trauma center over a 10-year period. Mechanism of injury, associated injuries, procedures, and follow-up data were collected, and all radiographs reviewed. Exclusion criteria included peri-implant fractures or evidence of pathologic fracture. A similar retrospective analysis was performed in a cohort of adult patients. Of 267 pediatric patients with femoral shaft fractures, 2 patients (0.7%) had ipsilateral femoral neck fractures. One femoral neck fracture was detected on initial plain radiographs and the other on a pelvic computed tomography (CT) scan. Both of these fractures resulted from high-energy trauma, which accounted for 92 (42%) of pediatric femoral shaft fractures. The cohort of 100 adults aged 18 to 89 years with femoral shaft fractures revealed 6 adult patients (6%) with ipsilateral femoral neck fractures, all from high-energy trauma. High-energy trauma accounted for 85% of the adult femoral shaft fractures, and was more common than in the pediatric population (P<0.005). The difference in incidence of ipsilateral femoral neck fracture between the pediatric (0.7%) and the adult group (6%) was significant (P=0.007). No missed or delayed diagnoses were identified. The incidence of associated ipsilateral femoral neck fracture in pediatric patients with femoral shaft fracture is very low (0.7%). Most (58%) pediatric femur fractures are caused by low-energy trauma. We were unable to demonstrate a need for routine CT scanning of the femoral neck in children with femoral shaft fractures. Given the increased risks of radiation exposure with younger and smaller patients, it does not appear that routine CT scanning low-energy pediatric femoral shaft fractures to evaluate for femoral neck fractures is justified unless there is a high level of clinical suspicion. Level II.

A Prospective Study of Efficacy of Titanium Elastic Nailing System (TENS) in Pediatric Femoral Shaft Fractures

A Prospective Study of Efficacy of Titanium Elastic Nailing System (TENS) in Pediatric Femoral Shaft Fractures

Leg Length Discrepancy and Angular Deformity after Flexible Intramedullary Nail fixation in Pediatric Femoral Shaft Fractures

Objective Femoral fracture is one of the most frequent fractures in children and complications occurs such as malunion and leg length discrepancy after internal fixation using flexible intramedullary nail. The author intended to consider operational treatment using flexible intramedullary nailing through a quantitative data including age, pattern and location of fracture for angulation, and leg length discrepancy. Methods A retrospective survey was performed by 30 cases of child patients who underwent internal fixation using flexible intramedullary nail for femoral shaft fracture. Using a simple radiography, duration of union and angulation were measured. Leg length discrepancy was evaluated by scanogram. By measuring each 2 times at an interval of 1 week by 2 observers, error among observers and error in observer were excluded. For statistical validation, t-test and lineal regression analysis were used. Results Immediate postoperatively, valgus condition of 7 degrees was represented and affected side was represented to show varus of 5.6 degrees on average in 46.6% of child patients. The more age of patient is young, more angulation was represented to be significantly taken place in transverse fracture rather than oblique fracture, but depending on fracture location, significant difference was not observed. Leg length discrepancy showed overgrowth of 6.39 mm on average. And cases of overgrowth over 5 mm being were represented and age of all the child patients was below 9 years old. As a result of statistical analysis, it was observed that the age is younger, leg length discrepancy was prone to be occurred, and its significant relevance with fracture form or fracture location was not represented. Conclusion Transverse fracture is represented at the time of performing internal fixation using flexible intramedullary nail. Occurrence rate of angulation and leg length discrepancy was high but follow-up period is required to be extended even after the time when growth is completed on a long-term basis and in case of imperfect correction, additional treatment such as physeal plate stapling is required. Bone shortening and lengthening may be required and it is considered to be a useful method for femoral shaft fracture of children. Key words: Femoral fractures; Fracture fixation; Intramedullary nailing; Leg length inequality; Lower limb deformity

6-12 yaş arası pediatrik spiral ve parçalı femur kırıklarında submuskuler plaklama ve eksternal fiksatör uygulaması etkinliği karşılaştırılması

Objective: The treatment of femoral diaphyseal fractures in children 6 to 12 years of age has changed substantially over the last two decades and continues to evolve. Although external fixation and submuscular plating have been extensively used in the management of pediatric femur fractures, there are few studies which have compared the results of external fixation and submuscular bridge plating in pediatric closed unstable spiral femoral diaphyseal fractures. Patients and Method: Two groups of patients treated by external fixator or submuscular plating due to femoral diaphyseal spiral and comminuted fractures were included in our study. Twenty patients comprised the external fixation group and 26 patients the submuscular bridge plating group. The patients were evaluated for mechanism of injury, knee ROM, length of hospital stay, clinical and radiological findings and complications. The average follow-up period was 2 (range: 1.5 to 4) years. Results: Age of the patients ranged from 6 to 11 (average: 7.45) years in the external fixator group and from 7 to 12 (average: 9.08) years in the submuscular plating group. In the external fixator group, the fixator was removed at an average of 12.2 weeks. In the submuscular plating group, radiographic union was detected at an average time of 10 weeks. Pin site infection was common in the external fixator group. Patients were given knee ROM rehabilitation for knee contracture. No refracture was observed in the external fixator and submuscular plating groups. Conclusion: The main point to consider in external fixator use in pediatric femur fractures is refracture after fixator removal, which is mostly seen in transverse and open fractures. Use of the external fixator in spiral fractures and removing the fixator following bone healing in four cortices may prevent refracture complication. It is the surgeon’s choice to decide between the two treatment modalities to operate on the femur fracture. Although we found similar results between external fixator and plate in pediatric femur shaft fractures; we think large population based studies are needed in order to comparison.

The outcomes of pediatric femoral shaft fractures treated surgically by different types of orthopedists

BackgroundThe objective of this study was to compare the outcomes of pediatric femoral shaft fractures treated with titanium elastic nail (TEN) by pediatric orthopedists and non-pediatric orthopedists. MethodsFrom May 2006 to June 2014, 88 children with femoral shaft fractures were randomized to operative stabilization either by pediatric orthopedists (Group A, 44 cases) or by non-pediatric orthopedists (Group B, 44 cases). Demographic data and clinical characteristics (age, sex, weight, fracture side and type, cause of injury, associated injuries and interval from injury to surgery) were comparable between the two groups before surgery. Peri-operative data, clinical and functional outcomes between the two groups were recorded. ResultsThe mean follow-up period was 20.9±4.5months for Group A and 20.0±3.6months for Group B (P=0.356). There was no significant difference in the time to union, length of hospitalization, full weight-bearing time and TEN scores between the two groups (P=0.785, P=0.835, P=0.803, P=0.940, respectively). However, the mean operating time and radiation time was longer in Group B than in Group A (P=0.001 and P=0.047, respectively). Also, there was a trend for patients of Group B to have a higher rate of open reduction (P=0.047). When comparing the total complications, no significant difference existed between the groups (P=0.978). ConclusionsThis study indicated that both pediatric and non-pediatric orthopedists provided satisfactory clinical and functional results in treating these common injuries.

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.

Management of paediatric femoral shaft fractures with titanium elastic nails

Femoral shaft fractures are the most common major paediatric injuries managed by the orthopaedic surgeon. Management is influenced by associated injuries or multiple trauma, fractures, personality, age and cost. Non-surgical management usually with early spica cast application is preferred in younger children. Surgery is common for the school age child and for patients with high energy trauma. In the older child, traction followed by casting, external fixation, flexible IM nails and plate fixation have specific indications. Potential complications of treatment include shortening, angular or rotational deformity, delayed union, non-union, overgrowth, infection, skin problems and scarring. Risks of surgical management includes refracture after external fixator or plate removal, osteonecrosis after rigid IM nail fixation and soft tissue irrigation caused by ends of flexible nails.

A clinical study on the surgical management of fracture shaft femur in children and adolescents by using Ender’s nail

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Femoral shaft fractures account for 1.6% of all pediatric bony injuries. Current treatment options include early spica casting, traction, external fixation, open reduction and internal fixation with plating, flexible intramedullary nails and intramedullary rods. Experience of many clinicians has shown that children with diaphyseal fractures do not always recover with conservative treatment. Ender rod fixation in the paediatric population is simple, effective and minimally invasive. It allows stable fixation, rapid healing and a prompt return of the child to normal activity. The objective of the study was to evaluate the functional outcome of the pediatric femur shaft fractures with Ender’s intramedullary nailing.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; 20 patients aged 5 to 16 years with fracture shaft of the femur treated with retrograde flexible intramedullary nailing at Bapuji hospital attached to JJM Medical College, Davangere in the period from September 2014 to August 2015 were included in the study.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; All patients were followed until fracture union occurred. The follow up period ranged from 6 months to 1 year. Results were analysed both clinically and radiologically. 1 case united within 8 weeks,14 cases in 10 weeks and 5 cases in 12 weeks. Out of 20 cases there is limb length discrepancy in 6 cases, infection in 2 cases, nail back out in 2 cases, varus malalignment in 2 cases, valgus malalingment in 3 cases, anterior angulation in 6 cases and rotational malalignment in 2 cases..&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Closed intramedullary nailing is an efficient method and does not expose the patient to an undue risk of infection or non-union. There is also no risk of limb length discrepancy and the angulation and rotational malalignment are within the acceptable limits. This safe procedure can be recommended in children with multiple injuries co-existent head injury and in age groups 5 to 16 years.&lt;/p&gt;

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.

The use of percutaneous joystick reduction and limited open reduction techniques in pediatric femoral shaft fractures: a study of 63 cases

Our study aimed to compare the effectiveness and clinical outcomes of percutaneous joystick reduction and limited open reduction for flexible intramedullary nailing in the treatment of pediatric femoral shaft fractures. A total of 63 pediatric femoral shaft fractures were studied: 35 fractures were treated with percutaneous fixation using the K-wire pin as a joystick (group A), whereas 28 fractures were treated with limited open reduction (group B). Clinical and radiographic data at the final follow-up were compared between the surgical groups. Their duration of X-ray exposure, postoperative weight-bearing time, healing time, Harris score, and Hospital for Special Surgery score at the last follow-up did not differ statistically. However, the blood loss, operative time, duration of hospital stay, and postoperative pain at the incision site were considerably lower in group A than in group B. Three and two patients from group A and group B, respectively, reported skin irritation, whereas one patient from group B developed infection. Seven patients in group A and eight patients in group B showed some extremity overgrowth (<2 cm) and no redisplacement or delayed union of fracture, iatrogenic vessel and nerve injury, or osteofascial compartment syndrome was reported in any of the groups. Therefore, we conclude that percutaneous joystick reduction may effectively be used for flexible intramedullary nailing in the treatment of pediatric femoral shaft fractures. Level III, retrospective comparative study.

Socioeconomic Factors Are Associated With Trends in Treatment of Pediatric Femoral Shaft Fractures, and Subsequent Implant Removal in New York State.

Disparities exist in access to outpatient pediatric orthopaedic care. The purpose of this study was to assess whether disparities also exist in elective pediatric orthopaedic surgical procedures such as implant removal, and to determine which demographic and socioeconomic factors may be associated with differences in treatment. Children aged 7 to 18 inclusive who sustained femoral shaft fractures between the years 1997 and 2010 were identified in the New York State SPARCS database. Patient age, sex, race/ethnicity, insurance status, education, and poverty were identified. Factors associated with the method of fracture treatment were assessed through multivariate regression analysis. The subset of patients that received internal fixation were followed up until 2011 inclusive for implant removal. Factors associated with implant removal were assessed using a Cox proportional hazards survival analysis (time to implant removal). Of the 3220 closed femoral shaft fractures identified, 2609 (81%) were treated with internal fixation, 9 (0.3%) had open treatment without implants, 203 (6.3%) were treated with external fixation, and 399 (12.4%) with closed methods. Patients with No Fault/Accident insurance by No Fault/Accident insurance were more likely to undergo internal fixation compared with patients with private insurance (P<0.001). Of the 3220 patients, 2572 were included in the implant removal subanalysis. Implant removal was performed in 725 (28.2%) patients. In the multivariate model, patients were more likely to undergo removal if they were younger (P<0.001), white [vs. black (P<0.001), vs. Hispanic (P=0.035), vs. other (P=0.001)], and lived in neighborhoods with less poverty (P=0.016). Insurance status was not a statistically significant predictor of implant removal. There is an association between implant removal and younger age, white race, and higher socioeconomic status in children. Awareness of these disparities should prompt further evaluation of causation, whether it be from lack of evidence-based guidelines for implant removal, surgeon bias, variations in reimbursement, or disparities in access to care. Further study is recommended to better elucidate the indications for implant removal in children and the causes for the disparities identified here. Level III-retrospective cohort study.

Overgrowth of the femoral neck after hip fractures in children.

BackgroundOvergrowth after pediatric femoral shaft fractures is well documented; however, overgrowth of the femoral neck after hip fractures has not been especially reported previously. The purpose of this study was to evaluate the incidence and characteristics of femoral neck overgrowth after hip fractures in children.MethodsFrom January 1990 to December 2012, there were 30 consecutive patients with pediatric hip fractures. We retrospectively reviewed the medical record of all the patients, including age at injury, gender, injury mechanism, fracture type, methods of treatment, time to bony union, and complications. The functional outcome was evaluated by Ratliff’s criteria. The radiography of the pelvis was performed in controlled positions of abduction and external rotation. The length of the femoral neck was measured by two observers. The overgrowth of the femoral neck was defined as lengthening more than 3 mm in comparison with the uninjured hip.ResultsAt a mean follow-up of 4.9 years (range 2–8 years), 12 patients (40 %) had an overgrowth of the femoral neck. The average overgrowth of the femoral neck was 6.2 mm (range 3.2–8.5 mm). The patients with femoral neck overgrowth were younger (p = 0.0002), have lower rate of avascular necrosis of the femoral head (p = 0.0006), and have better functional outcome (p = 0.0026).ConclusionsOur results provide evidence that overgrowth of the femoral neck following hip fractures may occur in children and the overgrowth phenomenon in the femoral neck was a predictor of good outcomes after treatment.

Treatment of pediatric femoral shaft fractures by stainless steel and titanium elastic nail system: A randomized comparative trial

PurposeLiterature suggests that the lower modulus of elasticity of titanium makes it ideal for use in children compared with stainless steel. Better fracture stability was observed in association with titanium nails on torsional and axial compression testing. However, stainless steel nails are stiffer than titanium counterparts, which may provide a rigid construct when fixing paediatric femoral shaft fractures. Complications have been observed more frequently by various researchers when titanium nails are used for fracture fixation in patients with increasing age or weight. The concept of this study was to compare the functional outcome after internal fixation with titanium elastic nail system and stainless steel elastic nail system in paediatric femoral shaft fractures. MethodsThe study was conducted on 34 patients admitted in the department of orthopaedics, LLRM Medical College & SVBP Hospital, Meerut, India from January 2013 to August 2014. We included patients aged 5–12 years with fracture of the femoral shaft, excluding compound fractures, pathological fractures and other lower limb fractures. Patients were treated by titanium (n = 17) or stainless steel (n = 17) elastic nail system and followed up for one year. The clinical parameters like range of motion at hip and knee joints, time to full weight bearing on the operated limb and radiological parameters like time to union were compared between two groups. A special note was made of intra- and post-operative complications. Functional outcomes were analysed according to Flynn criteria. ResultsBased on the Flynn criteria, 59% of patients had excellent results, 41% had satisfactory results, and no one showed poor results. There was no clinically significant difference between the two groups with respect to time to union and full weight bearing. But the incidence of puncture of the opposite cortex while inserting the nail and trying to advance it through the diaphysis during operation is greatly different. Only one such case was observed in titanium group but five in stainless steel group. ConclusionMajority of paediatric femoral shaft fractures are now treated operatively by elastic stable intramedullary nails. Operative intervention results in a shorter hospital stay and has economic and social benefits over conservative treatment. The cost of stainless steel nail is one third the cost of titanium nail. However, the clinico-radiological results are not significantly different between titanium and stainless steel nails at one year follow-up as observed by our study.

Are stainless steel elastic nails the solution to heavier children with femoral shaft fractures?

Background: The use of titanium elastic intramedullary nails for the treatment of femoral shaft fractures, in children weighing 45 kg, has been questioned due to the increased rates of malunion. Our aim was to see if the mechanical properties of stainless steel elastic nails provided enough fracture stability to justify their use in heavier children. Materials and Methods: Twenty pediatric femoral Sawbones®, fixed with titanium or stainless steel elastic nails, were tested. The bending stiffness and moments of the constructs were calculated at increasing loads, along with the angle of fracture deformation. From these estimates of maximum permitted body weight for each nail type were extrapolated. Results: Steel nails created significantly stiffer constructs than titanium in both the coronal and sagittal planes (P < 0.0001). Steel nails allowed bigger sagittal bending moments before losing acceptable alignment, compared to titanium (P < 0.0001). However, in the coronal plane, the difference was not statistically significant (P = 0.457). The estimated body weights extrapolated in the sagittal plane were 45 and 61 kg, in titanium and steel, respectively. In the coronal plane, they were 42 and 44 kg. Discussion: As steel has nearly twice the Young's modulus of titanium, it seems logical that fractures fixed with steel nails would be stiffer and fail at higher loads. However, it is unclear why steel did not outperform titanium in the coronal plane. A theory was proposed that unequal nail slip from the insertion sites might be a contributing factor to these findings. Conclusion: Pediatric femoral shaft fractures fixed with elastic steel nails provide significantly stiffer constructs than those fixed with titanium. However, there is an increased risk of malunion in the coronal plane, in children weighing 45 kg, regardless of material used, possibly due to unequal nail slip at the distal entry points.

CORR Insights®: Periosteal Fiber Transection During Periosteal Procedures Is Crucial to Accelerate Growth in the Rabbit Model.

W e know that excessive compressive forces across a physis can inhibit growth [1, 5], while tensile forces may cause growth stimulation. The role of the periosteum as a potential ‘‘tether’’ to the adjacent growth plate has been speculated in previous studies [8, 11]. Furthermore, clinical investigators have implicated the torn (‘‘untethered’’) periosteum as a contributor to limb overgrowth following a pediatric femoral shaft fracture and asymmetric medial physeal growth leading to genu valgum after certain proximal tibial fractures in young children [2, 3, 9]. Although studies have shown that leglength discrepancy can be addressed by transecting or stripping the periosteum of the shorter limb in young patients [4, 6, 8, 10], I believe that few surgeons currently apply these principles in clinical practice. Perhaps due to the reported unpredictability [10] and the lack of robust basic-science support, this seemingly straightforward method of growth stimulation of the short leg has not gained the popularity enjoyed by surgical alternatives, such as gradual lengthening or a contralateral epiphysiodesis. Additionally, it is currently unknown whether the various purported methods of untethering the periosteum are equally effective in inducing and sustaining growth stimulation of the affected extremity. In this well-designed animal study, Halanski and colleagues have dug deeper and studied the effects of four distinct methods of periosteal release on the growth rates and lengths of tibiae in skeletally immature rabbits. They found that simply stripping the periosteum around the proximal tibial metaphysis without transection of the longitudinal fibers did not enhance growth, while circumferentially transecting the periosteum, (with or without its removal) does stimulate growth at the proximal and distal tibial physes, as noted 2 weeks posto peratively. Although this growth stimulation was not sustained 8 weeks after surgery at the proximal tibial physis in the animals undergoing a one-time release, repeat transection at 4 weeks postoperatively seemed to reignite the physis. This latter group of This CORR Insights is a commentary on the article ‘‘Periosteal Fiber Transection During Periosteal Procedures Is Crucial to Accelerate Growth in the Rabbit Model’’ by Halanski and colleagues available at: DOI: 10.1007/ s11999-015-4646-6. The author certifies that he, or any member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/ licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR or The Association of Bone and Joint Surgeons. This CORR Insights comment refers to the article available at DOI: 10.1007/s11999015-4646-6. S. Sabharwal MD, MPH (&) Department of Orthopedics, Rutgers New Jersey Medical School, 90 Bergen Street, Suite 7300, Newark, NJ 07103-2499, USA e-mail: sabharsa@njms.rutgers.edu CORR Insights Published online: 4 January 2016 The Association of Bone and Joint Surgeons1 2015