Shaft Fractures In Children Research Articles

Management of displaced radius and ulna shaft fractures in children—should we be afraid of surgical intervention?

Management of displaced radius and ulna shaft fractures in children—should we be afraid of surgical intervention?

Operative Treatment of Completely Displaced Clavicle Shaft Fractures in Children

Journal of Pediatric Orthopaedics: October/November 2010 - Volume 30 - Issue 7 - p 746 doi: 10.1097/BPO.0b013e3181f231fb

Pre-bend elastic stable intramedullary nail fixation for distal radial shaft fractures in children

Objective To investigate the functional and radiographic outcomes of pre-bent elastic stable intramedullary nail in treatment of distal radial shaft fractures in children. Methods From January 2006 to December 2008, 18 children with distal radial shaft fracture were treated by close reduction and internal fixation with a pre-bent elastic stable intramedullary nail. The age range was from 5 years to 15 years,with an average of 9 years and 8 months. All the cases were closed fractures, and followed up at least 12 months. The time interval from injury to surgery were 1 to 9 days. Fracture sites were located at the distal radial shaft. Among them, 15 cases suffered ipsilateral ulnar fracture, and the others for solitery radial fracture. Closed reductions were performed under C-arm fluoroscopy. All affected arms were immobilized in the functional position postoperatively by the plaster cast beyond elbows. Results The average time of fracture complete union was 5 months (ranged from 3 months to 7 months). The average preoperative angulation of the fractures: anteroposterior view 16.2±7.5 degrees, lateral view 26.2±13.1 degrees. The average postoperative angulation of the fractures: anteroposterior view 2.7±1.5 degrees, lateral view 1.4±1.2 degrees. All fractures maintained good alignment postoperatively, and 94.4% (17/18) of the patients regained a full range of rotation of the forearm. One patient suffered limitation of rotation in forearm less than 10°, and this had improved by final follow-up. Complications included soft tissue irritation at the site of nail insertion in one patient and transient scar hypersensitivity in another. Conclusion Fixation with a pre-bent elastic stable intramedullary nail is an effective, safe and convenient method for treating distal radial shaft fractures in children. Key words: Child; Radius fractures; Fracture fixation, intramedullary

Pre‐bent elastic stable intramedullary nail fixation for distal radial shaft fractures in children

To investigate the functional and radiographic outcomes of pre-bent elastic stable intramedullary nail in treatment of distal radial shaft fractures in children. From January 2006 to December 2008, 18 children with distal radial shaft fracture were treated by close reduction and internal fixation with a pre-bent elastic stable intramedullary nail. The age range was from 5 years to 15 years, with an average of 9 years and 8 months. The minimum follow-up was 12 months. All fractures maintained good alignment postoperatively, and 94.4% (17/18) of the patients regained a full range of rotation of the forearm. One patient has limitation of rotation to less than 10°, this had improved by final follow-up. Complications included soft tissue irritation at the site of nail insertion in one patient and transient scar hypersensitivity in another. Fixation with a pre-bent elastic stable intramedullary nail is an effective, safe and convenient method for treating distal radial shaft fractures in children.

Failures and complications in intramedullary nailing of children's forearm fractures

There are published studies of outcomes in the use of ESIN that raise concerns about serious complications: the aim of this study is to report our experiences over 17years of use of this technique, which shows that complications and failures are insignificant when the method is applied correctly. We present a retrospective analysis of 553 children with forearm shaft fractures treated with elastic stable intramedullary nailing over a period of 17years. The 354 boys (64%) and 199 girls (36%) had an average age of 9.1years. A total of 61% of the fractures were located in the midshaft, 21% in the distal diaphyseal and 18% in the proximal third. Continuous documentation of treatment, postoperative course and follow-up after an average time of 37months formed the basis of this study. The analysis included all kinds of failures and complications. The following complications and problems were encountered: 5 children with wound infections and disturbed wound healing, 1 case of osteomyelitis, 7 children with ulnar non-unions, 14 children with delayed unions, 6 cases of loss of correction, 15 children with lesions of the superficial radial nerve, one case of malplacement of a nail, 5 children with skin perforations caused by the ends of implants and 27 children with refractures. The analysis of the failures and complications shows that a differentiated approach to the data has to be taken. Most complications occur because of incorrect use of the method with neglect of biomechanical principles. The usage of the ESIN method is extended to more problematic regions, such as the distal diaphyseal portion of the forearm, and therefore, an increase in complications is likely. Despite this risk, ESIN should still be the standard treatment for forearm shaft fractures in children, and no change in therapeutical strategy is necessary. However, it is of special importance to follow the right indication and to pay attention to biomechanical principles and to correct technical procedure.

Pediatric Humerus Fractures: Indications and Technique for Flexible Titanium Intramedullary Nailing

Background: Most fractures of the humeral diaphysis in children can be treated nonoperatively. In unusual situations surgical stabilization may be required. The purpose of this study is to describe the indications and surgical technique of titanium elastic nail fixation of humeral shaft fractures in children. Methods: Diaphyseal humerus fractures in children have been treated with intramedullary stabilization using titanium elastic nails. Complicating features that required operative stabilization include open fractures, fractures in which reasonable alignment could not be maintained without internal fixation, and patients with ipsilateral forearm fractures (floating elbow) and poly-trauma with associated lower extremity fractures necessitating early upper extremity weight bearing. Results: All fractures united without infectious or neurovascular complications. Nail migration requiring nail trimming or early implant removal occurred in a small number of patients and is the most frequent complication of the procedure. Conclusions: In situations in which surgical stabilization of pediatric humeral shaft fractures is necessary, titanium elastic nails provide an effective and simple option, allowing early motion and weight bearing.

小児大腿骨骨幹部骨折の治療経験

小児大腿骨骨幹部骨折の治療経験

Comparative Study of Fracture Shaft of Femur in Children Treated with Titanium Elastic Nail and Early External Fixator

Background: Although incidence of femoral shaft fracture in children is less than 2%, treatment of fracture shaft of femur is controversial. Material and Method: In this study we divide 30 patient in to two groups blindly and treat group I with retrograde titanium elastic nail (TEN) and group II with early external fixator. We have followed these patients for nine months and compile their results after noting the time of union, weight bearing and also the parents satisfaction with a questionnaire. Results: Duration of hospital stay was 4.7 days in group I and 2.8 days in group II. All the fractures healed satisfactorily. The average time for healing in the group I was 43.4 days and 70.26 days in group II. The average time for full weight bear-ing along with external fixator was 26 days while for group I was 42.7 days. Parents are more satisfied with intramedullary TEN. Conclusion: TEN is better option than that of external fixator for the management of fracture shaft of femur in children. Patients and their parents are more satisfied with TEN as compare to heavy external fixators.

Operative Treatment of Completely Displaced Clavicle Shaft Fractures in Children

Fractures of the shaft of the clavicle are common in both adults and children. Recent adult studies have indicated that improved outcomes are achieved after open reduction and internal fixation. The purpose of this study was to analyze outcomes after open reduction and internal fixation of displaced clavicle shaft fractures in children. We analyzed a retrospective case series of 24 children whose displaced clavicle shaft fractures were treated through open reduction and internal fixation. Special attention was paid to the rate of healing, radiographic outcomes, functional outcomes, and complications. Twenty-four children with an average age of 12 years and 8 months (range 7 to 16 y) had their closed unilateral clavicle shaft fractures treated via open reduction and internal fixation. Patients were followed for an average of 2 years and 2 months. There were no deep or superficial infections and no nonunions. Eighty-seven percent (21 of 24) of children returned to unrestricted sports activities. Two patients suffered from scar sensitivity and 1 patient experienced a transient ulnar nerve neurapraxia secondary to their initial injury. All fractures healed and all orthopaedic implants were later electively removed. We conclude that open reduction and internal fixation of displaced clavicle shaft fractures in children can be performed safely. Level 4, therapeutic study (retrospective case series).

Nonunion of forearm shaft fractures in children after intramedullary nailing

The elastic stable intramedullary nailing (ESIN) is the current treatment of choice for unstable forearm shaft fractures in children. There is no large study on paediatric nonunion of forearm shaft fractures in children after intramedullary nailing. There are only sporadic reports on nonunions after ESIN in children. The aim of this study was to define predisposing factors of nonunions in paediatric forearm fractures. All children who had been treated for forearm fractures by ESIN in our hospital from 1990 to 2006, and all children treated elsewhere surgically and being followed up at our institution were included in the study. In these children, we identified all patients who did not show bony consolidation of the fracture after 6 months from ESIN. Over a period of 16 years, 537 patients were primarily treated in our hospital and 55 children had been initially treated in a different institution. Six children were identified to fulfill the criteria of having developed a pseudarthrosis. Of these six children, three patients had been primarily treated in another hospital and three were our original patients. The average age was 11.1 years (9-14 years). There were only pseudarthroses of the ulna to be observed. In five children, the pseudarthrosis was in the middle third and in one patient in the distal third of the ulna. There were five closed fractures and one first-degree open fracture. Five times an open reduction of the ulna had been performed because closed reduction and insertion of the ESIN was impossible, whereas the radius had been treated closed in five cases and open in one case for intramedullary stabilization. Three cases were refractures, in one child it was a second refracture. In one case, we identified a technical error as cause of the development of the pseudarthrosis. Four children needed a revision surgery. In these children, the ulna was plated. Two patients showed spontaneous healing of the pseudarthrosis. In five patients, there was a hypertrophic pseudarthrosis present and in one case was hypotrophic pseudarthrosis. The reintervention was necessary because of increasing deformity in four patients and implant failure in one case. In conclusion, Non-unions after forearm fractures are observed in children and adolescents mainly in the middle third of the ulna. With the need of initial open reduction or the presence of an open fracture in the first instance, the risk of developing a pseudarthrosis. It may also be higher in such cases, which represent a refracture. Despite the small risk of developing a pseudarthrosis after forearm fracture, the indication for ESIN is clear. The surgical trauma needs to be as minimal as possible in cases with open reduction with as little as possible compromise of the blood circulation of the affected bone.

Early weight bearing after complete tibial shaft fractures in children

This study determined the prevalence of complications related to early weight bearing and the factors associated with time to healing in children after a complete tibial shaft fracture. Radiographs and medical records were reviewed from patients with unilateral, closed, complete tibial shaft fractures who were treated nonoperatively with a long leg cast. There were 55 males (68.8%) and 25 females (31.2%) with a mean ± SD age of 6.0 ± 4.0 years (range 1-16). There were few complications (2.5%) and patients healed faster if they bore weight earlier (0.3 days faster for each day earlier to weight bearing, P = 0.02), were younger (2.3 days faster per year younger, P < 0.001), were female (2.7 days faster than males, P = 0.02), or did not have a closed reduction (3.8 days faster, P = 0.002) (R = 0.63). Time to weight bearing after complete tibial shaft fracture was not associated with an increased risk of complications. Earlier weight bearing was associated with a shorter time to healing. This study provides support for treatment with early weight bearing in children with closed, complete tibial shaft fractures.

Die elastische stabile intramedulläre Nagelung als Therapiealternative in der Versorgung kindlicher Humerusschaftfrakturen

We report about our experiences with the elastic stable intramedullary nailing (ESIN) of traumatic humeral shaft fractures in children and adolescents. Children with traumatic humerus shaft fractures who were treated by ESIN were included. All patients underwent clinical follow-up examinations. 31 children (average age 11.4 years) with traumatic humeral shaft fractures could be included. There were 14 oblique, 12 transverse and 5 wedge fractures. In 5 cases the fracture was located in the proximal third, in 22 cases in the middle third and in 4 cases in the distal third. After an average period of 32 months a follow-up-examination with the Constant-Murley score was performed. All children attained 100 points and all patients could take part in sports activities like before the accident. 30 children and their parents were very satisfied with the treatment success and 1 patient was satisfied. The following complications were seen: 1 postoperative damage of the radial nerve in a patient with secondary fracture dislocation (complete remission), 1 skin irritation, 1 fracture dislocation with axial deviation, 1 secondary dislocation of the nails after a second accident and 1 secondary axial deviation. Elastic stable intramedullary nailing (ESIN) of humerus shaft fractures has a low complication rate if attention is paid to biomechanical principles. The observed complications are based on mistakes concerning the indication or technical errors. The ESIN shows very good functional and cosmetic results. It allows an early functional and cast-free follow-up with a quick pain reduction. The ESIN of humeral shaft fractures is a minimally invasive, simple and well reproducible technique with a steep learning curve. Because of the excellent objective and subjective results, the operative stabilization of humerus shaft fractures with ESIN should be recommended to the patients and their parents.

Comparative study of elastic stable intramedullary nailing and bone plate set in treatment of femoral shaft fractures in children

Objective To investigate and evaluate the efficacy of elastic stable intramedullary nailing (ESIN) and bone plate set (BPS) in the treatment of femoral shaft fractures in children. Methods The study involved 39 children with femoral shaft fractures, of whom 18 children were treated with ESIN (ESIN group) and the other 21 with BPS (BPS group). In ESIN group, the nails were insert-ed through a micro incision in the medial and lateral epicondyle after closed reduction under C - arm ob-servation. In BPS group, the plates were placed on the lateral side of femur by means of open reduction and internal fixation. Results All the patients were followed up for 4-20 months (mean 10 months), which showed fracture healing in all the patients. The mean operation time, incision length, perioperative blood loss, length of hospital stay, time of fracture healing and time of weight bearing were (40.0±17.0) minutes, (2.0±0.6) cm, (30.0±8.0) ml, (7.0±1.5) days, (8.0±1.2) weeks and (6.0 ±1.0) weeks respectively in ESIN group, and (70.0±25.0) minutes, (12.0±1.1) cm, (150.0±30.0) ml, (14.0±5.2) days, (13.0±1.9) weeks and (4.0±1.3) weeks respectively in BPS group, with statistical difference between two groups (P < 0.05). Conclusions Compared with BPS, ESIN has the advantages of less operation wound, less perioperative blood loss and shorter time for fracture healing. ESIN can protect the microenvironment important for the fracture healing, and is one of ideal op-tions for treatment of femoral shaft fracture in children. Key words: Femoral fractures; Child; Fracture fixation, intramedallary; Bone plate

Early reduction versus skin traction in the orthopaedic treatment of femoral shaft fractures in children under 6 years old

Femoral shaft fractures occur very frequently in children, and their prognosis usually is good. Nonoperative treatment is the gold standard for children under 6 years because of the excellent bony union and the remodelling qualities. The aim of this study was to compare two orthopaedic therapeutic methods: skin traction versus immediate reduction. The study involved 35 children, divided into two groups: in group 1, treatment consisted of skin traction for 21 days followed by hip spica casting; in group 2, an immediate reduction with early hip spica casting was performed. The ranges of motion, the delay before weight bearing, the hospitalisation duration and the required amount of painkillers were recorded. We compared initial shortening, axial, sagittal and rotational alignment, and femoral length discrepancy. We calculated the injured femoral diaphysal overgrowth and correlated it to the fracture type and location and to the initial shortening. Economical variables were also studied. The mean overgrowth was 8.9 mm in group 1 and 8.5 mm in group 2. Three years after the trauma, length discrepancy was 4 mm in group 1 and 1 mm in group 2. Hip spica casting leads to significant reductions in weight-bearing delay, hospitalisation duration and pain. The cost of treatment with skin traction was four times higher (24,472 euros) than that of immediate reduction (6,384 euros). Our results are in accordance with the literature. The femoral overgrowth was proportional to the initial shortening. Masculine gender, an oblique fracture and injury of the lower third of the femur were associated with the greatest femoral overgrowth. During the first year of follow-up, the femoral length discrepancy hardly varied after immediate reduction (4 mm), whereas the overgrowth reached 6 mm after skin traction. Overall, immediate hip spica casting leads to significant reductions in weight-bearing delay, hospitalisation duration, complications and costs, while having similar clinical results as traction.

The ortho-plastic management of Gustilo grade IIIB fractures of the tibia in children: A systematic review of the literature

Background The challenges of managing Gustilo IIIB tibial fractures in children are unique. A multi-disciplinary, evidence based approach is needed. We aimed to evaluate the evidence for the ortho-plastic management of Gustilo grade IIIB open tibial shaft fractures in children based on a review of all published data in order to rationalise the orthopaedic and plastic surgical approach to these complex injuries. Method A systematic review of the literature was performed. Gustilo grade IIIB tibial shaft fractures in pre-adolescent and adolescent children were identified and evaluated with regard to both the skeletal and soft tissue management, and the outcome. Results Of 54 children with grade IIIB tibial fractures, a mean union time of 31 weeks included 33 weeks for 42 adolescents and 23 weeks for 12 pre-adolescents. Faster union time in pre-adolescents tended towards significance. Delayed union occurred in 22%, nonunion in 13%, mostly in adolescents. Two of 45 covered by vascularised flaps and 3 of 9 treated without flaps developed deep infection ( p = 0.028). There was no correlation between method of skeletal fixation and union time. Conclusion Gustilo IIIB tibial shaft fractures in pre-adolescents tended towards faster healing with fewer complications, irrespective of the method of skeletal fixation. In adolescents, healing times were similar to adults. Soft tissue closure without flaps was associated with deep infection in one-third of patients, requiring debridement and flap cover. Adequate debridement and flap cover is suggested in all cases, irrespective of age.

Two cases of femoral shaft fractures in children with minimally invasive surgery

Two cases of femoral shaft fractures in children with minimally invasive surgery

Treatment of Fractures Of the shaft of the femur in children by Ender`s nails: A prospective study

We did a prospective study of 20 cases on treatment of fracture shaft of femur in children by Ender's nail. The average duration of hospital stay was 9 days. Femoral shaft fractures in children can be operatively treated with excellent results and a decreased complication rate. Operation results in shorter hospitalization which has psychological, social, educational, and economic advantages over conservative treatment.

Treatment of Complex Tibial Fractures in Children with the Taylor Spatial Frame

Most tibial shaft fractures in children can be treated with closed reduction and cast fixation, but some fractures need external or internal fixation. The Taylor spatial frame (Smith & Nephew, Memphis, Tennessee) is a relatively new external fixator that can correct 6-axis deformities with computer accuracy. This article reports our experience using the Taylor spatial frame as a rewarding treatment modality for complex tibial fractures in children and adolescents.

Use of end caps in elastic stable intramedullary nailing of femoral and tibial unstable fractures in children: Preliminary results in 11 fractures

Elastic stable intramedullary nailing (ESIN) is used routinely world-wide for treating femoral and tibial shaft fractures in children before skeletal maturity. Overall, ESIN allows rapid limb mobilisation with few complications. However, many centres have experienced some complications resulting from secondary fracture displacement, especially in heavy adolescents and in spiroid or complex fractures due to changes in the nail's position, leading to limb shortening, malrotation and malalignment. End caps were designed by the AO expert group to address these complications. The purpose of this study is to evaluate the efficiency, safety and tolerance of this new device in our first series of ten patients and 11 fractures. Prospective follow-up of our first ten patients operated on with end caps. Our results show that there were no serious complications at a mean follow-up of 13.1 months. There was only one 10-mm leg shortening in a patient in whom the end caps could not be properly inserted. There were no infections, no additional pain and no skin irritation. The use of end caps eased the removal of the nails after bone healing, thereby preventing the formation of ossification over the tips of the nails and appeared to protect the skin next to the nail tip. These results seem to prove the advantage of using end caps when performing ESIN in lower limb shaft fractures in children. A longer follow-up that includes more patients and a randomised prospective study should be carried out in the future to determine more precisely the indications of this new device.

Ipsilateral Femoral Neck and Shaft Fracture in Children

From the Department of Orthopaedics (A.A.), UCMS and GTB Hospital, Shahdara, Delhi, India; the ECHS Polyclinic (R.A.), Uttar Pradesh, India; and the Department of Orthopaedics (D.S.M.), SMS Medical College and Associated Hospitals, Jaipur, Rajasthan, India. Submitted for publication March 13, 2005. Accepted for publication August 3, 2005. Address for reprints: Anil Agarwal, MS, 131 Ankur Apartments, 7- I.P. Extension, Patparganj, Delhi 110092, India; email: [email protected].