Pediatric Femoral Shaft Fractures Research Articles

DOES TITANIUM ELASTIC NAIL (TEN) FOR FEMUR SHAFT FRACTURE IN CHILDREN HAVE SUPERIOR FUNCTIONAL OUTCOMES THAN SPICA CAST APPLICATION? AN EXPERIENCE FROM TERTIARY CARE HOSPITAL

This study aimed to compare functional outcomes in children with femur shaft fractures treated with ether titanium elastic nail or spica cast application. This prospective cohort study was conducted at the Department of Orthopedic and Spine, Aziz Bhatti Shaheed Teaching Hospital, Gujrat, from 1st June 2020 to 31st December 2022. This study involved 60 children of both genders, aged 3-6 years, presenting with femoral shaft fractures (Winquist I & II), randomly allocated into two groups for treatment. Patients in Group E were treated with titanium elastic nails, while a hip spica cast was applied to patients in Group S. Functional outcome was measured with the meantime to walk independently, which was noted and compared between the two groups. Patients had a mean age of 4.42±1.12 years, while the mean weight was 18.23±2.09 Kg. There were 21 (35.0%) female and 39 (65.0%) male patients with a male-to-female ratio of 1.9:1. The mean time to walk independently was significantly shorter in children treated with titanium elastic nail as compared to hip spica cast (5.60±1.28 vs. 8.93±1.98 weeks; p<0.001). A similar significant difference was observed between groups across various subgroups of patients based on age, gender, and weight. We concluded that internal fixation of pediatric femoral shaft fractures utilizing titanium elastic nail had superior functional outcomes as compared to hip spice cast application in terms of significantly shorter mean time to walk independently along with the minimally invasive nature of the procedure and better patient hygiene and cosmesis advocate preferred use of titanium elastic nails for management of such fractures.

TENS in Femoral Shaft Fractures of Children

Background: Pediatric femoral shaft fractures are one of the common fractures that we encounter in the orthopedics outpatient department. These fractures have various treatment options ranging from traction and early hip spica casting to elastic titanium intramedullary nails [titanium elastic nailing system (TENS)] and reamed intramedullary nails. In this study, we are evaluating the functional outcome and results following the use of flexible intramedullary nails and conservative management for femoral shaft fractures in children.
 Methods: This was a prospective observational study which was carried out in a tertiary care hospital from October 2015 to May 2017 for two groups of children who sustained traumatic femoral shaft fractures. A total of 40 patients were taken into consideration with 20 patients each in two groups.
 Results: The male-to-female ratio was 2.6:1 in our study population. The overall post-operative complication rate was more in the TENS group. Besides, we found that the TENS group of patients had a less limb length discrepancy (LLD) (P = 0.004) and a lower degree of angular deformity (P = 0.36).
 Conclusion: TENS demonstrated advantages including sufficient axial stability, early mobilization, and more rapid return to function than spica cast treatment; however, it had the drawback of possible infection and pin site irritation. Overall, TENS offers a minimally invasive method for treatment of the femoral shaft fractures in children which stands superior to traditional spica casting.

Can Rigid Femoral Nailing be used for Pediatric Femoral Shaft Fracture in Children 8 to 10 Years? Use of RIN in Patients With Femoral Shaft Fracture.

The treatment modalities for pediatric femoral shaft fractures are determined by their age, weight, and fracture pattern. Rigid intramedullary nailing (RIN) is usually recommended for patients >11 years of age, and elastic intramedullary nailing (EIN) has been used for patients under 10 years. However, little is known about the use of RIN in patients aged 8 to 10 years. We examined the differences in patients with femoral shaft fractures who were treated with EIN or RIN in terms of (1) fracture healing; (2) changes of anatomic parameters; and (3) related complications. We retrospectively reviewed 54 patients between 8 and 10 years of age, with femoral shaft fractures, who were treated with either EIN or RIN between 2011 and 2020. Lateral trochanteric entry was used for RIN procedure. The mean follow-up period was 26.4 months (range, 6 to 113mo). There were 17 patients in the EIN group and 37 patients in the RIN group. The mean age at the time of surgery was 1 year younger in the EIN group (P<0.01). The mean weight of the patient was significantly heavier in the RIN group compared with the EIN group. Complete union of the fracture was achieved slightly faster in the RIN group at 3.4 months compared with 3.7 months in the EIN group (P=0.04). There were no clinically significant changes of the anatomic parameters in either group, including neck shaft angle and articulotrochanteric distance. There was no evidence of avascular necrosis at the time of final follow-up for either group. There were no significant differences in postoperative complications between the groups. RIN using lateral trochanteric entry is a feasible surgical option for femoral shaft fractures in patients 8 to 10 years of age that are heavier than 40kg or with unstable fracture patterns. Level III, retrospective cohort study. See the Guidelines for Authors for a complete description of levels of evidence.

Functional outcome of pediatric femoral shaft fractures treated with TENS nailing: A case series of 25 patients

TENS (Titanium Elastic nailing system has become the standard treatment for pediatric femoral shaft fractures in the age group 6-14 years. The other treatment options are traction plus spica casting and external fixation. In spite of excellent results described in various studies, there still exists disunity in the orthopedic fraternity with regards to its usefulness. The aim of this study is to determine the outcome of pediatric femur fractures treated with TENS nailing. Between September 2020 and November 2022, 25 children within the age group of 3-12 years with femoral shaft fractures were included in the study. Two TENS nails of precalculated size were inserted in a retrograde fashion under fluoroscopic guidance. Patients were followed up at regular intervals to assess clinical and radiological parameters. Final results were evaluated using Flynn’s clinical criteria. Results: There were 14 males and 11 females with an average age of 6.8years. Fracture levels included N=6 subjects (24%) proximal third fractures. N=15 (60%) subjects with Middle third fractures. N=4 (16%) subjects presented with Lower third fractures. Open injuries were present in 6 cases and 19 cases with closed injuries. The mean injury to surgery interval was 2.37 days, mean hospital stay was 7.3 days and mean time to union was 8.16 weeks. Severe complications were severe skin irritation with bursitis requiring early nail removal in one case, delayed union in one case, Results were excellent in 13(52%) patients, satisfactory in 10 (40%) patients and poor in 2(8%) patients. Conclusion: TENS is safe, reliable and an effeciant method of fixation owing to its simplicity, minimal invasiveness, ease of insertion and removal, TENS additionally has better cosmesis, rapid union with short rehabilitation, less psychosocial stress to the patient and family.

Racial Disparities in Outcomes Following Open Treatment of Pediatric Femoral Shaft Fractures.

Introduction Femoral shaft fractures are a common pediatric injury that can require non-operative or operative management. Several studies have shown that race impacts pain management and a number of emergency department visits in the pediatric femur fracture population. This study aimed to investigate any association between pediatric patient race and number of comorbidities, 30-day postoperative outcomes, and length of stay following open surgical treatment of femoral shaft fractures. Methods Pediatric patients who underwent open treatment of femoral shaft fracture were identified in the National Surgical Quality Improvement Program-Pediatric database from 2012-2019. Patients were categorized into two cohorts: White and underrepresented minority (URM). URM groups included Black or African American, Hispanic, Native American or Alaskan, and Native Hawaiian or Pacific Islander. Demographics, comorbidities, and postoperative complications were compared using bivariate and multivariable regression analyses. Results Of the 5,284 pediatric patients who underwent open treatment of femoral shaft fracture, 3,650 (69.1%) were White, and 1,634 (30.9%) were URM. Compared to White patients, URM patients were more likely to have a higher American Society of Anesthesiologists score (p=0.012), more likely to have pulmonary comorbidities (p=0.005), require preoperative blood transfusion (p=0.006), and have an increased risk of prolonged hospital stay (OR 2.36; p=0.007). Conclusion Pediatric URM patients undergoing open treatment of femoral shaft fractures have an increased risk of extended hospital stay postoperatively compared to White patients. As the racial and ethnic constitution of the pediatric population changes, understanding racial and ethnic health disparities will be crucial to providing equitable care to all patients.

Do All Pediatric Femoral Shaft Fractures Need a Computed Tomography Scan of the Ipsilateral Femoral Neck? Calculating the Incidence of Concomitant Femoral Neck and Shaft Fractures

In adults, the incidence of ipsilateral femoral neck fractures in the setting of femoral shaft fractures is reported to be as high as 9%; however, scant literature exists on the same clinical scenario in pediatric/adolescent populations. Therefore, the purpose of this study was to investigate the incidence of ipsilateral femoral neck fracture in the setting of femoral shaft fractures in children and adolescents treated in pediatric hospitals across the United States. The Pediatric Health Information System database was queried for patients aged 18 years or younger who were treated for a femoral neck, femoral shaft, and pertrochanteric femur fractures through an emergency department, inpatient, ambulatory surgery, or observation visit. Patients were identified using ICD-9 and ICD-10 diagnosis codes. Data from 49 pediatric hospitals between the years 2002 and 2020 were included. Incidence was calculated as the number of cases including the event divided by the total number of cases. A total of 90,146 records were identified from a cohort of 55,733,855 (0.16%). Distal femur fractures, pathologic fractures, and periprosthetic fractures were excluded, resulting in 65,651 unique cases. Of the 65,651 cases, 7104 (11%) were identified as isolated neck fractures. The combined incidence of femoral neck or pertrochanteric femur fractures in the setting of a femoral shaft fracture was 82.3 per 10,000 cases (0.82%). Only 283 cases of concomitant femoral neck and shaft fractures were found among 55,169 femoral shaft fractures (0.5%). The incidence of ipsilateral femoral neck or pertrochanteric femur fractures in the setting of a femoral shaft fracture is 82.3 per 10,000 patients (0.82%) based on data from Pediatric Health Information System-participating institutions. The incidence of femoral neck/pertrochanteric femur fractures and femoral shaft fractures in children and adolescents is more than 10 times lower than reported for adults; therefore, the routine use of advanced diagnostic imaging in pediatric patients with femoral shaft fractures should be considered cautiously. Level IV; cross-sectional analysis.

Paediatric Femoral Diaphyseal Fractures in a South Wales Tertiary Centre: An Account of Trend in Management and Complications Over 16 Years.

Femoral shaft fractures in children have seen a number of interesting developments over the past 20 years. This is a retrospective cohort study looking into epidemiological and outcomes data of femoral shaft fractures in children treated at a tertiary centre in Wales from 2005-2021. Over a period of 16 years, there has been a significant increase in the number of rigid or elastic nailing and submuscular plating, coinciding with a dramatic reduction of external fixation for definitive treatment of diaphyseal femoral fractures. All patients above five years of age underwent operative fixation, with elastic or rigid intramedullary nailing the treatment of choice. Following multiple linear regression with 16 possible explanatory factors, this study found a statistically significant increase in time to union for open fractures, pre-operative translation, and operation time. Furthermore, there was a significant increase in post-operative leg length discrepancy for right versus left-sided fractures. Overall complication rates were 4% for minor and 8% for major complications. Complication rates were lowest for rigid intramedullary nailing and highest for external fixation. No cases of avascular necrosis were found for 27 rigid intramedullary nails inserted. Overall this study reports treatment choices and outcomes in keeping with current trends in management for paediatric femoral shaft fractures.

Outcome of Ender’s nailing in pediatric patient with Shaft of Femur Fracture in a Tertiary Care Hospital

&#x0D; Introduction: The use of spica casting in children with the shaft of femur fractures is controversial. Presently, &#x0D; operative treatment is the main standard for the management of shaft of femur fractures in children. The &#x0D; advantages of Ender’s nail are closed insertion of the nail with the preservation of fracture hematoma, minimal &#x0D; chances of infection and the endosteal blood supply is preserved because no reaming is required.&#x0D; Objective: To determine the treatment outcome of Ender’s nailing in the pediatric shaft of femur fractures in &#x0D; terms of limb length discrepancy, function, and union.&#x0D; &#x0D; &#x0D; Materials and Methods: This descriptive study was conducted at Orthopaedic Department, Benazir Bhutto &#x0D; Hospital, Rawalpindi Medical University, Rawalpindi from January 2017 to December 2019. We enrolled 95 &#x0D; children 6-12 years of age by using a non-probability consecutive sampling technique with femoral shaft fracture. &#x0D; The exclusion criteria include children with pathological fractures, malignancy, and skeletal dysplasia. Time of &#x0D; surgery, implant failure, infection, union, limb length discrepancy, and functional outcome were recorded. &#x0D; Functional outcome and union were determined by using Flynn criteria and radiographs while the surgery time, &#x0D; infection, limb length discrepancy, and implant failure were determined clinically.&#x0D; &#x0D; &#x0D; Results: There were 59 (62.1%) male and 36 (37.89%) female children. The mean age was 6.93 ± 4.12 years. The &#x0D; mean surgery duration was 30 ± 8.5 minutes. There were 06 (6.31%) superficial and no patients with deep &#x0D; infection. No implant failure in our study. The time duration from radiological &amp; clinical union to full weight &#x0D; bearing was 7.9 weeks (5-12 weeks). On Flynn criteria, 67 (70.52%) children had excellent and 28 (29.47%) had a &#x0D; satisfactory functional outcomes. In 85 (89.47%) children, there was no limb length discrepancy but 10 (10.5%) &#x0D; children had limb length discrepancy with a mean of 5.45 ± 1.23 mm. &#x0D; &#x0D; &#x0D; Conclusion: Ender’s nailing is an excellent treatment option for the pediatric shaft of femur fractures in terms of &#x0D; functional outcome and union with low chances of infection, limb length discrepancy, and implant failure.&#x0D; &#x0D; &#x0D; Keywords: Ender’s nailing, pediatric femoral shaft fracture, union, functional outcome, infection, implant failure, &#x0D; limb length discrepancy&#x0D; &#x0D;

Treatment of Pediatric Femoral Shaft Fractures.

Diaphyseal femur fractures are common in pediatric orthopaedic settings. A patient-specific treatment plan incorporates several factors, including age, weight, fracture pattern, associated injuries, and social considerations. Nonaccidental trauma should be considered in children younger than 3 years. In general, young children are treated with noninvasive immobilization (Pavlik harness or early hip spica casting) while school-aged children are treated with internal fixation. Internal fixation options include flexible intramedullary nails, rigid locked intramedullary nails, and plate osteosynthesis. Flexible intramedullary nails have the best outcomes in children of appropriate weight, aged 5 to 11 years, with stable fracture patterns. Lateral-entry rigid intramedullary nails have been designed for use in older children. External fixation is usually reserved for complex scenarios. Regarding all treatment methods, surgeons should be aware of several technical factors necessary to optimize outcomes.

Study on outcome of treatment of paediatric femoral shaft fracture by titanium elastic nails

Background: Although the incidence of paediatric femoral shaft fractures is about 1.6%, it’s treatment is controversial, especially in children of age 6-12 years. Materials and Methods: This prospective observational study was performed at Sher E Bangla Medical College Hospital, Barishal, Bangladesh from January 2020 to December 2020, on 7 children (n=7). There were limited number of patients included due to this study accomplished in the perphery city of Bangladesh. Both male and female children with simple transverse and short oblique fractures were included. Results: Among the 7 cases, 6 were closed femoral shaft fracture and 1 was Gustilo Anderson type 1 open fracture. The mean age of the patients was 8.57 years, ranging from 5-13 years. 6 were male and 1 was female, with a male female ratio of 6:1. In 4 cases right side was affected and in 3, left side was affected. 5 cases were treated by closed reduction and the rest 2 cases were treated by open reduction. The average union of fracture was 9.7 (6-15) weeks. Results were evaluated using Flynn et al scoring criteria, with 4 excellent, 2 good and 1 poor outcome during the 5-11 months follow up period. Conclusion: Titanium elastic nailing has considerably decreased the period of immobilization, ensured early return to normal life and provides psychological advantages. It provides better outcome in simple transverse of short oblique mid diaphyseal femoral fractures.

Functional outcome of elastic intramedullary nailing for femoral shaft fractures in children

Background: Pediatric femoral shaft fracture is the most frequent fracture type in orthopedic practice in which males are affected more commonly than females. Currently, intramedullary fixation for the managing of femoral shaft fracture in children is widely used worldwide, including Iraq, which overcomes most of the difficulties related to other treatment modalities. Objectives: This study aimed to determine the clinical, functional, and radiological consequences of pediatric femoral shaft fractures achieved with a titanium elastic nail system (TENS). Materials &amp; Methods: In this study, 28 children aged 5-10 years with femoral shaft fracture admitted to Shar Hospital, Sulaimaniyah, Republic of Iraq, were enrolled. Their fractures were fixed with Titanium Elastic Nail (TEN), in which a pair of the same-sized nail was used for each fracture. The outcomes were assessed using Flynn’s scoring criteria. Finally, the patients were discharged the next day and followed up after 2, 4, 8, 12 and 20 weeks of surgery. Results: Based on Flynn’s score assessment, the outcome of 85.71% of patients were excellent, 12.5% were satisfactory, and 1.79% were poor. All patients were showed a radiological unification and a conceivable full weight-bearing in a mean time of ~ 9 weeks, while their full knee variety of movement was attained in 2 months. Conclusions: TENS is a potential means to treat femoral shaft fractures in children as it is a simple, safe, minimally invasive, and physeal-protective with fewer complications and a high rate of good and excellent outcomes.

Can Titanium Elastic Nails be the First Treatment Choice in Pediatric Femoral Shaft Fractures?

Can Titanium Elastic Nails be the First Treatment Choice in Pediatric Femoral Shaft Fractures?

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.

Titanyum elastik çivi ile tedavi edilmiş pediatrik popülasyondaki femur şaft kırıklarının klinik ve radyografik olarak değerlendirilmesi

Aim: The main goal of study is to evaluate the clinical, functional and radiographic results of titanium elastic nail (TEN), which is among the most preferred methods in the treatment of pediatric femoral shaft fractures.&#x0D; Materials and Methods: In this study, 33 patients, the ages of from 4 to14 years and weighing less than 50 kg, who were diagnosed with femoral shaft fractures between January 2018 and December 2019 and operated on with the TEN method in our clinic, were evaluated retrospectively. The demographic information of the patients, injury mechanism, fracture pattern, duration of surgery, radiographic union time, degree of residual deformity in the coronal and sagittal planes after union, nonunion rate, leg length discrepancy and postoperative weight-bearing times were examined.&#x0D; Results: Femoral shaft fractures were seen 2.3 times more often in boys than in girls. Patients are often injured as a result of high-energy trauma such as traffic accidents and falls from a height. According to radiographic measurements, mean residual deformity of 3.23 ± 2.46 degrees in the coronal plane and 4.56 ± 3.78 degrees in the sagittal plane was measured and a mean discrepancy of 1.36 ± 0.85 cm was found between the two legs. Radiographic union time was calculated as 10.41 ± 3.55 weeks on average.&#x0D; Conclusion: If applied with the right indication and the right technique, the TEN method is extremely important and successful in the treatment of femoral shaft fractures in pediatric patients younger than 15 years old and weighing less than 50 kg.

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

Flexible Intramedullary Nail Versus Submuscular Locked Plate with the Cluster Technique in Pediatric Femoral Shaft Fractures Fixation.

The aim of this study is the comparison between the flexible intramedullary nail and submuscular Locked Plate with the cluster technique in fixation of pediatric femoral shaft fractures at the age group between 6 and 12years old with simple diaphyseal closed or Gustilo open grade I fractures. Fifty children aged 6-12years with femoral fractures were enrolled in this study. The children were randomly assigned equally to the two groups for fractures fixation. The follow-up period was 1year. A comparison of various parameters and outcomes between both groups was documented. No significant differences were detected between both groups regarding the age, gender, affected side, mechanisms of fracture, or fracture classifications. The operative time and radiation time were longer in the plating group, while the amount of blood loss was lesser in the nail group. The patients treated with plating had better results concerning knee range of motion, weight-bearing, malalignment, and length discrepancy, with fewer complications and better functional outcomes. The result of the present study supports the use of submuscular locked plate with cluster technique in the treatment of studied fractures over flexible IMN.

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.

Complication rate after femoral shaft fractures in childhood and adolescence depending on patient factors and treatment measures

HintergrundDie Behandlung der Femurschaftfrakturen bei Kindern war in den letzten Jahren einem zunehmenden Wandel unterzogen. Die früher dominierenden Therapieverfahren wurden durch minimal-invasive Techniken (z. B. elastisch stabile intramedulläre Nagelung [ESIN]) weitgehend abgelöst. Ziel der vorliegenden Studie war der Vergleich der Komplikationsraten in Abhängigkeit sowohl von Patientenfaktoren als auch von verschiedenen Behandlungsverfahren.Material und MethodenBei der vorliegenden Arbeit handelt es sich um eine retrospektive röntgenmorphometrische Datenauswertung. Es wurden die Patientenakten und Röntgenbilder von 101 Kindern, die an zwei Level-I-Traumazentren behandelt wurden, ausgewertet.ErgebnisseIn 19 % der Fälle wurde eine konservative Therapie durchgeführt. Bei den operativen Verfahren dominierte die ESIN-Technik (n = 60). Revisionspflichtige Komplikationen fanden sich nach konservativer Therapie bei ca. 10 % der Kinder. Bei den operativ behandelten Kindern musste in über 6 % der Fälle eine Revisionsoperation durchgeführt werden. Die ESIN-Stabilisierung zeigte bei den operativen Verfahren mit ca. 3 % die niedrigste Revisionsrate. Wurden im Verhältnis zum Markraumdurchmesser zu dünne ESIN-Drähte verwendet, so zeigte sich eine um 30 % höhere Komplikationswahrscheinlichkeit. Bei Kindern unter 3 Jahren und Adoleszenten war die Komplikationswahrscheinlichkeit erhöht.DiskussionIn der durchgeführten Studie zeigt sich ein moderates Komplikationsrisiko bei der Behandlung von Femurschaftfrakturen bei Kindern. Das Komplikationsrisiko nach Fixateur-externe-Anlage und konservativer Behandlung war in dieser Studie am höchsten. Die ESIN-Technik zeigt insgesamt das geringste Komplikationsrisiko. Die vorliegende Arbeit konnte die bekannten Limitationen der ESIN-Technik in Abhängigkeit von Alter und Gewicht bestätigen.

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.

Retrograde Intramedullary Nailing of Pediatric Femoral Shaft Fractures Does Not Result in Growth Arrest at the Distal Femoral Physis-A Retrospective Cases Series.

To evaluate femoral growth after placement of retrograde intramedullary nails in the treatment of pediatric femoral shaft fractures. Retrospective case series. Large urban trauma center in Mongolia. Twenty-nine pediatric patients who sustained a diaphyseal femoral shaft fracture were included in the study. Retrograde intramedullary nail fixation with the standard, fin, or pediatric fin Surgical Implant Generation Network nail across an open distal femoral physis. The main outcome measure was the distance traveled by the intramedullary nail with respect to the distal femoral condyles and distal femoral physis from initial surgery to follow-up. The mean age of patients was 10.7 years (range: 7-14 years). Follow-up occurred at a mean of 292 days (range: 53-714 days). Both condyle distance and physis distance were significantly positively correlated with follow-up days, with Pearson R values of 0.90 (P < 0.001) and 0.84 (P < 0.001), respectively. Multiple regression analysis revealed that follow-up days was the only significant predictor of physis distance, whereas age, sex, percent growth plate violation, and nail fully traversing physis were not significant predictors. The nail completely crossed the physis in 5 patients and no growth arrests were found. This is the first study, to our knowledge, to evaluate treating femoral shaft fractures with a retrograde nail across an open distal femoral physis. In the pediatric population, the use of a retrograde femoral intramedullary nails does not seem to cause growth arrest of the injured femur during the postoperative period and may be a reasonable treatment option when other surgical options are not available. Additional study is necessary to further evaluate the safety profile. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.