Pediatric Femoral Shaft Fractures Research Articles

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

The Results of Retrograd Intramedullary Elastic Nailing in the Treatment of Pediatric Femoral Shaft Fractures

The aim of this study was to evaluate the results of retrograd intramedullary nailing treatment in children with femoral shaft fracture. METHODS: In this study, 20 patients, were included who applied to Mustafa Kemal University Research Hospital and were treated with retrograd intramedullary elastic nailing because of femoral shaft fracture. RESULTS: The mean age of our patients was 14.5 months (9–24 months) and mean follow-up time was 8.3 years (4.5–14 years). The average length of stay in hospital were 3.4 days. The average reunion duration were detected as 7.8 weeks. There was no significant difference between reunion durations of open and closed fractures. Valgus alignment of 7 degrees was observed in one patient and 5 degrees in one other patient. But it did not result any functional or clinical restrictions. There were not any increase of anterior-posterior angle or any rotational deformities observed. Extremity length difference below 1cm was detected in 3 of the patients and length difference between 1–1.5 cm was detected in 2 patients. When patients were evaluated according to Flynn’s criteria, the results were excellent in 14 patients (70%), good in 5 patients (25%) and poor in 1 patient (5%). CONCLUSION: Elastic intramedullary nailing treatment of femoral shaft fractures in children between 5–14 years of age is a safe and effective treatment.

Comparative Study between the Elastic Nail versus Hip Spica Cast in Early Treatment of Pediatric Femoral Shaft Fractures

Introduction: Femoral shaft fractures are among the most common pediatric injury, which have the highest incidence among other pediatric fractures, and treatment of them carries a lot of controversies. Aim of the study: To compare the outcome of fixation of femoral shaft fracture by elastic nail with Spica cast. Patient and method: This prospective comparative study was carried out in Sulaimani Teaching Hospital, in the period from the 10th of December 2011 to the 10th of June 2012, for two groups of children whose ages were between 4 - 12 years (average 6.61 years), sustained traumatic femoral shaft fractures with follow-up period of about 6 months. The first group was consisting of 30 children treated by Elastic Intramedullary Nail, while the second group was consisted of 30 children treated by hip Spica. The selection was made on random bases. Results: Age range was between 4 - 12 years and showed male predominance in both groups with ratio of about 2:1 while fracture site showed predominance of the midshaft pattern in both groups. This study showed highly significant deference (P value of 0.001) between the two groups (Spica group of 3 days versus Nail group median of rate 4.5 days) in the admission period. Our sample showed shortening of about 2 cm in 2 case in the Nail group (6.7%) versus 6 cases (20%) in Spica group. We reported 4 cases of wound infection (13.3%) and 4 cases of pin site irritation (13.3%) in nail group. A higher rate of malunion was observed in the Spica group (10 cases more than 10° angulation in coronal plane) while the Nail group reported 2 case more than 10° in coronal plane. The mean operative time for Nail group was 55 minutes while in Spica group was 30 minutes. We reported shorter time to start mobilization and walking with support or independently in the nail group (weight bearing time 7.2 weeks) compared with the Spica casting group (weight bearing time 7.5 weeks). Conclusion: Elastic nail fixation yields better outcome for femoral shaft fracture in form of easier child handling, parent’s satisfaction, and maintaining acceptable fracture alignment.

KIRSCHNER WIRE VERSUS TITANIUM ELASTIC NAILS IN PEDIATRIC FEMORAL SHAFT FRACTURES.

ABSTRACTObjective: To evaluate the effectiveness of intramedullary fixation using the Kirschner-wire (K-wire) compared to the titanium elastic nail (TEN) in pediatric femoral shaft fractures. Methods: A sample of 42 pediatric patients with a mean age of 6.55±2.42 years (range 4-11 years) presenting femoral shaft fractures underwent intramedullary fixation using the K-wire or TEN. Results: There was no significant difference found between groups, of which 16 (38.1%) patients were treated with K-wire and 26 (61.9%) patients were treated with TEN in terms of union duration. Moreover, none of the patients showed nonunion or a delayed union. Conclusions: The use of adjusted K-wire instead of TEN in the intramedullary fixation of femoral shaft fractures in selected children may be an advantageous surgical option due to the lower cost, easy accessibility and no need for a second surgery for implant removal. Level of Evidence III, Retrospective Study.

Preliminary Report: Pediatric Femur Fractures: Single Incision Intramedullary Stabilization Technique.

Pediatric femoral shaft fractures are common injuries that have seen a trend toward surgical stabilization. Traditionally these fractures have been stabilized with flexible intramedullary nails performed through a 2-incision technique. We proposed that a single incision technique would offer equivalent outcomes with the potential for improved cosmesis and a reduced infection risk. A retrospective review was performed of 112 consecutive cases of pediatric femoral shaft fractures, 66 cases were excluded, leaving 23 cases utilizing the single incision technique and 23 utilizing the standard 2-incision technique. Electronic medical records were then reviewed for demographic information, and a PAC system was employed to classify the fractures according to the AO classification and determine the time to fracture union. No significant difference was found in fracture healing times with a mean union time of 62.4 and 50.3 days in the single and double incision groups, respectively (P=0.38). One complication of superficial infection was noted in the 2-incision group; however, this was not statistically significant, and no malunions or nonunions were detected in either group. A single incision technique for intramedullary stabilization of pediatric femoral shaft fractures is a viable option with an equivalent time to fracture union and no observed difference in the complication rate. Furthermore, the technique may offer benefits with regard to infection risk and cosmesis.

Pediatric femoral shaft fractures treated by flexible intramedullary nailing

BackgroundNowadays pediatric femoral fractures are more commonly managed with operative treatment rather than conservative treatment because of more rapid recovery and avoidance of prolonged immobilization. Children between the ages of 5–13 years are treated either by traction plus hip spica and flexible/elastic stable retrograde intramedullary nail, or external fixators in the case of open fractures. The aim of this study is to evaluate the outcome of pediatric femoral shaft fractures treated by stainless steel flexible intramedullary nail in children between 5 and 13 years of age. MethodsThere were 32 cases of femoral shaft fractures which were all fixed with stainless steel flexible intramedullary nail under fluoroscopy. Long leg cast was applied at the time of fixation. Partial weight bearing was started 2 weeks after surgery. Patients were evaluated in follow-up study to observe the alignment of fracture, infection, delayed union, nonunion, limb length discrepancy, motion of knee joint, and time to unite the fracture. ResultsWe were able to follow up 28 out of 32 patients. The patients were 8.14 years of age on average. The mean hospital stay after operation was 4 days and fracture union time was 9.57 weeks. There were 3 cases of varus angulation, 2 cases of anterior angulation, and 4 cases of limb lengthening. ConclusionPatients aged between 5 and 13 years treated with flexible intramedullary nail for closed femoral shaft fracture have rapid union and recovery, short rehabilitation period, less immobilization and psychological impact, and cost-effective.

March Image Quiz: Pediatric Femoral Shaft Fracture

Journal of Orthopaedics for Physician Assistants 3(2):p 17-18, Spring 2015. | DOI: 10.2106/JBJS.JOPA.15.00069

Pediatric Femoral Shaft Fractures Treated With Titanium Elastic Nailing

The objective of this study was to prospectively compare intraoperative fluoroscopy time and clinical and radiological results in pediatric femoral shaft fractures treated with titanium elastic nailing (TEN) using a small-incision, blind-hand reduction vs closed reduction. From February 2008 to December 2009, sixty-eight children were enrolled in the study. Patients were divided into 2 groups: group A comprised 34 patients treated with a small-incision, blind-hand reduction technique and group B comprised 34 patients treated with a closed reduction technique. Operative time, intraoperative fluoroscopy time, fracture union time, and complications were recorded in both groups. Clinical and radiological results were assessed using the TEN scoring system. Mean operative time was 30.5±8.5 in group A and 53.0±15.0 minutes in group B, and mean fluoroscopy time was 28.4±18.5 seconds in group A and 65.0±28.5 seconds in group B. Operative time and fluoroscopy time were significantly longer in group B (P<.001). According to the TEN scoring system, the results were excellent in 31 patients and good in 3 patients in group A and excellent in 29 patients and good in 5 patients in group B. There was no significant difference between the 2 groups in terms of clinical and radiological results. There was also no significant difference in terms of fracture healing time, weight-bearing time, and complications. The small-incision, blind-hand reduction technique provided similar clinical results as closed reduction. This technique could be an alternative to closed reduction because it significantly reduced intraoperative radiation exposure and operative time.

Titanium elastic nailing in pediatric femoral diaphyseal fractures in the age group of 5-16 years - A short term study.

Management of femoral diaphyseal fracture in the age group of 5-16 years is controversial. The purpose of this study is to demonstrate the effectiveness of intramedullary fixation of femoral shaft fractures by using titanium elastic nailing system (TENS). Between April 2011 and April 2014, 40 pediatric patients (31 boys, 9 girls) aged 5-16 years with diaphyseal femoral fractures were treated by retrograde TENS fixation. Fractures were classified according to system of Winquest and Hansen as Grade-I (n=18), Grade-II (n=10), Grade-III (n=7) and compound fractures according to the Gustilo and Anderson's classification Grade-I (n=3), Grade-II (n=2). The final results were evaluated by using Flynn's criteria. The mean duration of follow-up was 21 months (range 3-39 months). All fractures were radiologically united with grade 3 callus formation at 8-10 weeks period (mean 9 weeks) and full weight bearing was possible in a mean time of 9.5 weeks. According to Flynn's criteria, excellent result was found in 33 patients (82.5%) and satisfactory in 7 patients (17.5%). Limb lengthening was noticed in 6 cases, varus mal-alignment was in 4 cases and rotational mal-alignment was seen in 3 cases. Peri-operative difficulties encountered were failure of closed reduction in 4 cases and cork screwing of nails in 2 cases. TENS is a safe and effective method for the treatment of pediatric femoral shaft fractures, because it is minimally invasive, relatively easy to use and shows very good functional and cosmetic results.

Luau Limbo and the Age for Rigid Nailing of Pediatric Femoral Fractures: How Low Can You Go? Commentary on an article by Samuel N. Crosby Jr., MD, et al.: "Twenty-Year Experience with Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients".

Pediatric femoral fractures are typically treated with age-dependent protocols that consider both the growth and remodeling potential of the femur and patient characteristics such as weight and socioeconomic environment of the child. Although it is generally agreed that children five years of age or younger can be adequately managed with a spica cast for length-stable femoral fractures, the range of treatment options for patients between the ages of five years to skeletal maturity span the gamut of flexible nailing, submuscular plating, external fixation, and trochanteric entry rigid intramedullary nailing. Piriformis entry rigid nails are generally shunned in pediatric practice because of a clear association with osteonecrosis1. Trochanteric entry rigid intramedullary nailing is advantageous in treating pediatric femoral shaft fractures in several respects. First, when compared with flexible nails, proximal and distal interlocking allows unmatched length and rotational control of complex injuries. Second, this load-sharing device does not fear the obese child2. Finally, the average orthopaedic surgeon is well trained in this technique and can offer reproducible results. For a femoral fracture in a child nearing skeletal maturity, the choice of rigid intramedullary nail fixation generates no particular debate. However, great concern exists for children with the …

Additional Tension Screws Improve Stability in Elastic Stable Intramedullary Nailing: Biomechanical Analysis of a Femur Spiral Fracture Model.

For pediatric femoral shaft fractures, elastic stable intramedullary nailing (ESIN) is an accepted method of treatment. But problems regarding stability with shortening or axial deviation are well known in complex fracture types and heavier children. Biomechanical in vitro testing was performed to determine whether two modified osteosyntheses with an additional tension screw fixation or screw fixation alone without nails could significantly improve the stability in comparison to classical ESIN. A total of 24 synthetic adolescent-sized femoral bone models (Sawbones, 4th generation; Vashon, Washington, United States) with an identical spiral fracture (length 100 mm) were used. All grafts underwent retrograde fixation with two C-shaped steel nails (2C). Of the 24, 8 osteosyntheses were supported by one additional tension screw (2C1S) and another 8 by two screws (2S) in which the intramedullary nails were removed before testing. Each configuration underwent biomechanical testing in 4-point bending, external rotation (ER) and internal rotation (IR). Furthermore, the modifications were tested in axial physiological 9 degrees position for shifting and dynamic compression as well as dynamic load. Both screw configurations (2C1S and 2S) demonstrated a significantly higher stability in comparison to the 2C configuration in 4-point bending (anterior-posterior, 0.95 Nm/mm [2C] < 8.41 Nm/mm [2C1S] and 15.12 Nm/mm [2S]; posterior-anterior, 8.55 Nm/mm [2C] < 12.65 Nm/mm [2C1S] and 17.54 Nm/mm [2S]; latero-medial, 1.17 Nm/mm [2C] < 5.53 Nm/mm [2C1S] and 9.15 Nm/mm [2S]; medio-lateral, 1.74 Nm/mm [2C] < 9.69 Nm/mm [2C1S] and 12.20 Nm [2S]; all p < 0.001) and during torsion (ER, 0.61 Nm/degree [2C] < 4.10 Nm/degree [2C1S] and 9.29 Nm/degree [2S]; IR, 0.18 Nm/degree [2C] < 6.17 Nm/degree [2C1S] and 10.61 Nm/degree [2S]; all p < 0.001]. The shifting in compression in 9 degrees position was only slightly influenced. The comparison of 2S versus 2C1S showed more stability for 2S than 2C1S in all testing, except the axial 9 degrees compression tests for shifting. In contrast to the 2C configuration, both modifications (2C1S and 2S) turned out to be stable in dynamic 9 degrees axial compression with a force of 100 up to 1,000 N at 2.5 Hz in 250,000 load cycles. In this in vitro adolescence femur spiral fracture model, the stability of ESIN could be significantly improved by two modifications with additional tension screws. If transferred in clinical practice, these modifications might offer earlier weight bearing and less problems of shortening or axial deviation.

Pitfalls of femoral titanium elastic nailing.

Despite several potential complications of elastic intramedullary nailing, it is currently the treatment of choice for femoral diaphyseal fractures in school-aged children. This study aimed to critically evaluate the complications of titanium elastic nailing in pediatric femoral shaft fractures. This study evaluated patients with a diaphyseal femoral fracture treated with titanium elastic nailing (TEN) in Tampere University Hospital in Finland. The study group included 32 children with a mean age of 9 years during a 5-year period, from 1 January 2003 to 31 December 2007. Data were collected from medical records and x-rays. Mean follow-up time was 42 months. Of 32 patients, 9 (28%) reported a postoperative complication. Complications were associated with nail prominence in five (16%) patients and instability in four (12%) patients. In patients with nail prominence, the titanium elastic nailing-nail ends were unbent and 10-35 mm outside the cortex of the distal femur. The nail prominence caused pain and delayed knee mobilization until the nail was removed after a mean time of 4 months. In patients with fracture instability, the mean titanium elastic nailing-nail/medullary canal diameter ratio was 46% and periosteal callus formation was 5.4 mm at the first control. In those with stable fractures, the values were 66% and 9.2 mm, respectively. Based on this study, two types of pitfalls in a small volume center were found. Titanium elastic nail ends were left unbent and too long. We recommend palpating the nail ends to exclude nail prominence and to verify free movement of the knee after nail cutting and bending. Fracture instability was caused by inserting titanium elastic nailing-nails that were too narrow. To avoid this complication, careful preoperative planning to select the proper-size titanium elastic nailing-nails and intraoperative testing of fracture stability under continuous fluoroscopy after the operation is advised.

External fixation for closed pediatric femoral shaft fractures: where are we now?

Recent advances in external fixation technique and pin design have sought to minimize complications such as pin site infection and premature removal of the external fixator. Although newer forms of internal fixation have gained popularity, external fixation may still have a role in managing pediatric femoral shaft fractures. We sought to assess the time to healing, limb alignment, and complications observed in a cohort of pediatric patients with closed femoral shaft fractures who were treated with external fixation. Over a 15-year period, one surgeon treated 289 pediatric patients with femur fractures, 31 (11%) of whom received an external fixator. The general indications for use of an external fixator during the period in question included length-unstable fractures, metadiaphyseal location, refracture, and pathologic fracture. Six patients (19%) had inadequate followup data and four patients (13%) were treated with a combination of flexible intramedullary nails and external fixation, leaving 21 patients for analysis. Mean age at injury was 10years (range, 6-15years) and followup averaged 22months (range, 5-45months) after removal of the fixator. Radiographs were examined for alignment and limb length discrepancy. Complications were recorded from a chart review. Mean time in the fixator was 17weeks (range, 9-24weeks). One patient sustained a refracture and one patient with an isolated femur fracture had a leg length discrepancy>2cm. There were no pin site infections requiring intravenous antibiotics or additional surgery. One patient with Blount disease and previous tibial osteotomy developed transient peroneal nerve palsy. Despite improvements in pin design and predictable fracture healing, complications such as refracture and leg length discrepancy after external fixation of pediatric femoral shaft fractures can occur. However, external fixation remains a viable alternative for certain fractures such as length-unstable fractures, metadiaphyseal location, pathologic fractures, and refractures. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Principles &amp; Outcome of treatment by Titanium Elastic Nails for Diaphyseal fracture of femur in Children

For treatment of pediatric femur shaft fractures in Children of age less than five years; there has been no controversy prevails and can be best treated by traction followed by cast method as proved by number of studies because of early union and rapid remodeling. Children with age higher than five years have more chances of malunion and plaster complication. Our study on pediatric diaphyseal femoral fractures at these age group shows good outcome with closed reduction and fixation by Titanium Elastic Intramedullary Nails; as compare to traditional methods like conservative traction followed by cast method, open reduction and plate fixation, external fixator as they have their possible drawbacks in results described by conventional studies.

Antegrade rigid nailing through the tip of the greater trochanter for pediatric femoral shaft fractures

The aim of this work was to evaluate the results of rigid nailing of pediatric femoral shaft fractures inserted antegrade through the tip of the greater trochanter. Twenty-three femoral shaft fractures in 23 children were fixed with rigid interlocking nails inserted through the tip of the greater trochanter at Mansoura Emergency Hospital in the period between June 2009 and August 2011. The average age of the patients at the time of injury was 12.6 years (range 9.2-15 years). The final follow-up radiographs were assessed for evidence of avascular necrosis (AVN) of the femoral head and any deformity of the proximal femur, the neck-shaft angle, the articulotrochanteric distance, and the femoral neck diameter. Patients were followed to a mean period of 31 months (range from 25 to 36 months) postoperatively. All fractures united in a range of 9 weeks (from 8 to 13 weeks) with no limb length discrepancy more than 2 cm and no clinically evident rotation in either direction; no case had a vascular necrosis of the femoral head or significant proximal femoral deformity by the final follow-up. Fixation of fractures of the shaft of the femur in children with rigid interlocking nails inserted through the tip of the greater trochanter is a rigid way for fixation controlling rotation and length. It is a safe technique without causing AVN of the femoral head or proximal femoral deformity.

Comparison Between Closed (Immediate Spica, Traction/Spica Cast) and Open Fixation (Plate Fixation) in Femoral Shaft Fractures in Children Below Nine Years Old Who Had Recoursed to Mashhad Imam Reza Hospital From 2002 to 2007

lower third (distal) femoral shaft fractures. Thirteen fractures (50%) were treated with immediate Spica cast, six fractures (23%) received traction and Spica cast, and surgical fixation with plate was carried out in the remaining seven cases. Results: After a follow-up interval of at least 5 years, angle deformity was the most common complication observed in 32% of the studied patients. Limb length discrepancy and rotational deformity were observed in 24% and 16% of the cases. Treated with immediate Spica cast proved to have the highest complication prevalence of all (92.2%) and was followed by traction and Spica cast (83.4%) and were observed in patients' surgical fixation with plate (14.3%). Conclusion: According to the results, internal fixation with plates can be considered an appropriate technique in cases of pediatric femoral shaft fractures.

Elastic Nailing for Pediatric Subtrochanteric and Supracondylar Femur Fractures

Subtrochanteric and supracondylar femur fractures are difficult injuries to treat in children. Although elastic stable intramedullary nails are commonly used for pediatric femur shaft fractures, there is little information on their effectiveness for managing pediatric subtrochanteric and supracondylar femur fractures. We (1) evaluated radiographic union rates and fracture alignment after elastic nailing of pediatric subtrochanteric and supracondylar femur fractures, (2) identified complications, and (3) determined risk factors for complications. Between 2005 and 2011, 36 subtrochanteric fractures and eight supracondylar femur fractures were treated with elastic stable intramedullary nails and had complete followup until clinical and radiographic union. Elastic nailing was used for subtrochanteric fractures in children 5 to 12 years of age or after failed spica cast treatment in younger children and for displaced supracondylar fractures in children older than 5 years. Fracture alignment and union were measured on radiographs, and complications were identified from review of patient charts. Patients with and without complications were compared using nonparametric tests to identify risk factors. All fractures healed; 23 of 33 (70%) subtrochanteric femur fractures and five of seven (71%) supracondylar femur fractures healed with anterior angulation of about 5°. For subtrochanteric fractures, complications included repositioning/removal of nails before radiographic union (n = 4), malunion (n = 2), fracture (n = 1), irritation (n = 1) at nail insertion site, and limb length discrepancy (n = 1); despite these complications, there were 22 (61%) excellent, 12 (33%) satisfactory, and only two (6%) poor outcomes. For supracondylar fractures, complications included infection after nail removal (n = 1) and nail site irritation (n = 2); there were three (38%) excellent, five (62%) satisfactory, and no poor outcomes. Complications were more likely after subtrochanteric fracture during motor vehicle accident (p = 0.045). Although complication rates are high with elastic nailing for pediatric subtrochanteric (22%) and supracondylar (38%) femur fractures, elastic nailing represents an important option for difficult-to-manage femur fractures. Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Pediatric femoral shaft fractures: treatment strategies according to age - 13 years of experience in one medical center

ObjectiveThe objective of this study was to analyze our experience in treating femoral shaft fractures with different strategies, focusing on the first year after injury when the choice of method would have the greatest impact.MethodsWe reviewed the medical records of all children treated for femoral shaft fractures in our institution between 1997 and 2010. They were divided according to therapeutic approach: spica cast, skin traction, titanium elastic nail (TEN), external fixator, intramedullary medullary nail (IMN), and plating.ResultsThe 212 patients included 150 boys and 62 girls (M/F ratio 2.4:1, mean age 5 years, range 0–16). The postoperative radiographic results demonstrated solid union in all patients, with no malunions. Of the 151 children in the spica cast group, 10 required re-manipulation and casting due to loss of reduction with unaccepted angulation, 10 had contact dermatitis, and 2 had fever and pressure sores. All 21 elastic nail group children underwent re-operation to remove the hardware: 3 had soft tissue irritation at the insertion points, and 3 had leg length discrepancy (LLD). Of the 14 external fixation patients, 4 had LLD, 1 had a pin tract infection, and 1 had a fracture through a pinhole after a fall. There were no complications in the 12 IMN patients, the 3 plating patients, or the 11 skin traction patients. LLD rates in the spica group were 10.5% higher compared to those in the control group (other treatment modalities) (P = .03).ConclusionsTEN treatment was superior to spica casting for children who had reached an average age of 4 years.

Technique to aid elastic nailing of paediatric femoral shaft fractures

Femoral fractures account for less than 2% of all paediatric orthopaedic injuries, with an annual rate of 19 per 100,000 in the USA. Hitherto, this injury was managed in a plaster hip spica and this remains the case for children under the age of 3 years. However management for older children has shifted to a more operative approach, due to improved technologies associated with a reduction in soft-tissue trauma. This results in a more rapid recovery, shorter hospital stays, earlier mobilisation and social reintegration. In 1982 a team from Nancy, France, popularised a technique using flexible nails to internally splint femoral fractures. This technique entails the use of two opposing flexible implants to balance forces and provide a load-sharing device that enables stability in flexion, translation, rotation and axial load. In their study this procedure produced excellent results and advantages of flexible intramedullary nailing (FIN) comprise early fixation and mobilisation, minimally invasive fixation and improved alignment. Subsequently, several studies have also reported excellent results but the technique itself can be challenging and studies focusing on complications of FIN have reported rates of 10–50%. Common complications include malalignment, malunion, soft tissue irritation (at the insertion site), nail prominence and migration, fracture shortening, leg length discrepancy and delayed union. Some of these complications can be directly linked to technical difficulties intraoperatively. Lohiya et al. reported the need for open reduction in 16% of femoral fractures treated with elastic intramedullary nails. Narayanan et al. reported that in a cohort of 79 fractures, 10 required re-operation and 8 were mal-aligned whilst Kaiser et al. found 8 out of 50 fractures required reoperation and identified technical errors in implantation in 3 of these cases. The Nancy technique describes initial fracture reduction (with traction) followed by the introduction of intramedullary