Interventions for treating femoral shaft fractures in children and adolescents

Plate fixation versus flexible intramedullary nails for management of closed femoral shaft fractures in the pediatric population: A systematic review and meta-analysis of the adverse outcomes

Purpose

Fractures of the femoral diaphysis are associated with a risk of morbidity in children. Various fixation methods have been developed, but with only limited evidence to support their use. This systematic review assesses the evidence regarding clinical outcomes of closed femoral diaphyseal fractures in children treated with plate fixation or flexible intramedullary nails.

Methods

A PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis were conducted. MEDLINE, Embase, and Web of Science (WoS) databases were searched from inception to February 2023. Inclusion criteria included clinical studies reporting adverse outcomes following surgical treatment of pediatric closed femoral diaphyseal fractures using plate fixation and flexible intramedullary nails. The ROBINS-I and RoB 2 tools evaluated the risk of bias.

Results

Thirteen papers (2 prospective randomized controlled trials and 11 retrospective cohorts) reported 805 closed diaphyseal femoral fractures in 801 children (559 males, 242 females). There were 360 plate fixations and 445 flexible intramedullary nails. Two cases of osteomyelitis and one nonunion were reported. Meta-analysis showed that plate fixation had a lower risk of soft tissue infection (relative risk 0.26 (95% confidence interval 0.07-0.92)). There was no difference in the following outcomes: malunion (relative risk 0.68 (95% confidence interval 0.32-1.44)); unplanned reoperation (relative risk 0.59 (95% confidence interval 0.31-1.14)), and leg-length difference (relative risk 1.58 (95% confidence interval 0.66-3.77)). The risk of bias was high in all studies.

Conclusions

An analysis of 805 fractures with minimal differences in meta-analyses is considered high quality even when the quality of the evidence is low. The findings are limited by important flaws in the methodology in the published literature. Well-designed multicentre prospective studies using standardized core outcomes are required to advise treatment recommendations.

Level of evidence

III.

THE RELATIONSHIP BETWEEN FRACTURES IN PEDIATRIC POLYTRAUMA PATIENTS: EVALUATION OF CLINICAL OUTCOMES

Objective

To evaluate children and adolescents with polytrauma and fractures of the pelvis and proximal and diaphyseal femur and correlate the impact of these conditions and clinical outcomes.

Methods

Retrospective study carried out in a public hospital in Taboão da Serra (SP), with pediatric patients with polytrauma from January 2012 to December 2021. In total, 44 patients were evaluated, 70.44% boys and 29.55% girls, aged from 12 to 17 years.

Results

Diaphyseal fracture of the femur affected 70.44% of the patients, mainly caused by a fall from a height (56.81%). Linear external fixation was the most used treatment (45.45%). All patients were discharged from hospital.

Conclusion

We found essential sociodemographic information: 84.11% of patients did not have associated injuries; 88.63% were hospitalized from 3 to 11 days; 90.91% did not need to be admitted to an ICU, 77.27% did not need reoperation, and 22.73% underwent another surgery; 45.45% used the external fixator to stabilize injuries; 11.36% converted the external fixator to the intramedullary nail; 9.09% needed an intramedullary nail remover; 2.27% converted to a plate (bilateral) and 2.27% to a rigid nail; 2.27% had loss of reduction and revision with rod; 2.27% underwent corrective osteotomy; 2.27% had clinical hospitalization; 2.27% had osteonecrosis of the femoral head and screws removed; 2.27% removed the plate. No deaths were recorded. Level of Evidence II, Retrospective Study.

Flexible intramedullary nails or Spica casting? A meta-analysis on the treatment of femur fractures in preschool children aged 2-5 years

The objective of this study is to conduct a meta-analysis (1) to evaluate outcomes of flexible intramedullary nails (FIN) versus Spica casting for treating femur shaft fractures in children aged 2-5 years and (2) to investigate the associated complications. The PubMed , Cochrane Library , Embase and Web of Science databases were searched to identify available studies comparing the outcomes of FIN and Spica casting for the treatment of femoral shaft fracture in preschool children. Meta-analysis was conducted with adherence to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Eight observational studies involving 4995 patients were included. Two were judged to be of moderate quality, with the remainder being high quality. There were 1573 patients treated by FIN and 3422 by Spica casting. Compared to Spica casting, FIN allowed a quicker return to normal activities (40.49 ± 13.43 vs. 46.97 ± 14.32 days; P  < 0.001), had a lower incidence of malunion (0.88 vs. 4.19%; P  = 0.01) and unplanned interventions (2.87 vs. 7.53%; P  < 0.001), but had slightly longer hospital stay (2.01 ± 1.01 vs. 1.10 ± 0.93 days; P  = 0.01) and required a second surgery to remove the nails. Compared with Spica casting, FIN has the advantages of faster returning to normal activities and lower incidence of residual deformities and unplanned reoperation, but a slightly longer time of hospitalization and needs a second surgery to remove the hardware. Existing studies on duration of care and financial burden are insufficient, so further studies are warranted on multicenter and high-level evidence studies. Level of evidence: III.

Preventing pressure ulcers from paediatric femoral traction: use of an audit cycle to assess a new concise manual and a daily care chart

INTRODUCTION

Femoral shaft fractures are common in children up to 14 years of age and traction is frequently used during their treatment. A lack of training and unfamiliarity of junior doctors and nursing staff with this treatment modality may lead to unfavourable skin complications, especially in the absence of regular monitoring. We introduced and audited a simple and reproducible way of monitoring these patients.

METHODS

An initial audit was conducted of all children with femoral shaft fracture treated in skin traction. A new traction manual and daily care chart were introduced, and a re-audit was performed. A parallel survey regarding skin traction in children was conducted involving 33 hospitals in the United Kingdom.

RESULTS

The initial audit showed three patients (23%) developed grade 2 pressure sores with a mean duration of traction of 8.5 days. A pressure sites check was documented in only 7.7%. A re-audit, after introduction of the traction manual and daily care chart showed a mean duration of traction of 8.4 days and only one patient (12.5%) developed a grade 1 sore. Pressure site monitoring improved significantly with 75% documentation. No daily care chart was used among the 33 centres in the survey and only 27% of centres had access to a manual in the ward.

CONCLUSIONS

Introduction of a single-page traction manual and a daily care chart into patient care notes to effectively monitor for pressure areas in children on skin traction helps reduce the incidence of serious skin complications.

Suitability of skin traction combined with braces for treating femoral shaft fractures in 3-5 years old children

BACKGROUND

In children aged 3-5 years, femoral fractures are common and are frequently treated using flexible intramedullary nails (FIN) or spica casting. Recently, more surgeons have been relying on FIN surgery because of the high rate of complications associated with spica casts, such as skin irritation and re-adjustment surgery. We aimed to evaluate the effect of skin traction combined with braces in 3-5 years old children at our hospital.

METHODS

We retrospectively analyzed 125 children aged 3-5 years with femoral shaft fractures treated at our hospital between January 2010 and December 2020. We assigned 68 patients who underwent FIN surgery to Group A and 57 patients treated with skin traction and braces to Group B. Comparative analysis included the children's age, sex, side of the affected limb, cause of fracture, function of the knee joint, healing time of the fracture, duration of hospitalization, cost of hospitalization, and complications. The complications evaluated included joint dysfunction, pain, infection, pressure ulcers, angular deformities, limb length differences, re-fractures, nonunion fractures, and delayed union.

RESULTS

There were significant differences in and hospital costs (p = 0.001). Conversely, no statistically significant differences were observed in sex (p = 0.858), injury type (p = 0.804), age (p = 0.231), hospitalization time (p = 0.071), bone healing time (p = 0.212), and complications. Pressure ulcers, nonunion fractures, and delayed union did not occur in both groups.

CONCLUSION

Both methods had similar therapeutic effects and postoperative complications in children aged 3-5 years with femoral shaft fractures. Therefore, skin traction combined with braces is recommended for this population and for patients hospitalized in institutions where several beds are available, with a consequent possibility of prolonged hospitalization.

LEVEL OF EVIDENCE

IV.

Flexible nails have a significantly increased risk of complications compared with plating techniques when treating diaphyseal femoral fractures in children aged 5-12: A systematic review

BACKGROUND

One third of paediatric femoral fractures occur between the ages of 5 and 12. The American Academy of Orthopaedic Surgeons (AAOS) provide evidence-based guidance for treating such fractures that occur in children under 5 and over 12 but not for this age cohort. We aimed to synthesise the available evidence comparing flexible nailing versus plating techniques for diaphyseal femoral fractures in children between the ages of 5 and 12.

METHODOLOGY

A systematic review of interventional and observational studies was performed using MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, WHO Global Index Medicus and LILACS. The search strategy combined keywords for: children, diaphyseal femoral fractures, plates and nails. Two independent reviewers screened, selected, assessed quality and extracted data from identified studies. The primary outcome was overall complication rates. Secondary outcomes assessed rates of individual complications, and operative variables (e.g. operative time, blood loss).

RESULTS

Five studies fulfilled the eligibility criteria. No RCTs were identified. The studies included 308 femoral fractures in 306 patients: 174 fractures were treated with flexible nailing and 134 with plating. The post-operative complication rate was 27.0% (n = 47) after flexible nails and 12.7% (n = 17) after plating, relative risk 2.13 (95% CI 1.28, 3.53; p = 0.0035). The relative risk of malunion was 3.59 (95% CI 1.05, 12.25; p = 0.0409) with flexible nails and of prominent metalwork was 5.39 (95% CI 1.25, 23.31; p = 0.0241) with flexible nails.

CONCLUSIONS

Data on this topic for this age group is limited despite accounting for one third of paediatric femoral fractures. This review identified a significantly increased relative risk of all complications, and in particular with respect to malunion and prominent metalwork when fractures in this cohort are treated with flexible nails compared to plates. A multi-centre randomised trial to determine if either treatment is superior would be justified.

TREATMENT OF PEDIATRIC FEMORAL FRACTURES IN THE CITY OF ZAGREB

Femur fractures in children can be treated with a number of operative and conservative methods. Numerous factors determine which method is optimal for a specific fracture. The aim of this research was to analyze distribution of femur fractures in children living in the urban communities of Zagreb and Zagreb County by localization, type and frequency of treatment methods used according to age and fracture mechanism. The research included 103 children aged up to 18 years, treated for femur fractures at the Zagreb University Hospital Centre and Zagreb Children’s Hospital. Data were collected from these institutions and a retrospective study covered the 2010-2015 period. The cause of fracture and diagnosis were coded with the help of the International Statistical Classification of Diseases and Related Health Problems. Operative treatment was applied in 55% of cases, which is contrary to previous researches. The highest incidence of femur fractures was recorded in the 0- to 4-year age groups, accounting for 49.1% of all fractures. These fractures mostly occurred due to falls and were more often treated with non-operative methods. All other age groups were mostly treated with operative methods. Coxofemoral immobilization and traction were used as non-operative methods, whereas flexible intramedullary nailing was the most frequently used operative method. The treatment depended on age, complexity of the fracture, fracture type, fragment displacement, and associated injuries. The cause was also an important factor on choosing the treatment method. Non-operative treatment was mostly used for fractures caused by falls (64.71% of cases due to falls) and operative treatment was mostly used for fractures caused by traffic accidents (79.4% of cases due to traffic accidents). It is a wide-known opinion that the best treatment for femur fractures in children is non-operative treatment. However, recent studies have shown that the use of operative methods in femur fracture treatment is growing. Our cohort of children treated during a five-year period (2010-2015) also underwent operative treatment more often than non-operative one. Two non-operative and eight operative methods were used. With such a large number of methods, it is clear that there is no unique method for all fractures. However, it is clear that the trend of using operative treatment is connected to the perennial trend of considerable sociodemographic and socioeconomic changes in urban settings such as Zagreb. Lifestyle changes directly affect the prevalence of femur fractures among children, as well as approach to treatment choice. General opinion is that most of fractures that occur at an early age can be treated with non-operative methods. Our research on femur fractures in children confirmed this rule. The youngest age group that had the highest incidence of fractures (49.1% of all fractures) was treated with non-operative methods in 75% of cases. Operative methods prevailed in other age groups. Similar results have been published by other authors. In conclusion, nearly half of all femur fractures (49.1%) occurred at a young age (0-4 years). Diaphysis fractures were most common. Most of the fractures that occurred during the 2010-2015 period were treated with operative methods, mostly in children aged 5-9 years. Out of eight different operative methods, elastic stable intramedullary osteosynthesis was most frequently used (60%). Coxofemoral immobilization and traction were used as non-operative methods.

Tendency towards operative treatment is increasing in children's fractures: results obtained from patient databases, causes, impact of evidence-based medicine

Results of numerous studies assessing the national or the local patient databases in several countries have indicated that the overall rate of operative treatment in fractures, as well as the rate in certain upper and lower limb fractures, has significantly increased in children. The most prominent increase in the rate of operative treatment was observed in forearm shaft fractures.

Results of several survey studies have revealed that there was not a high level of agreement among paediatric orthopaedic surgeons concerning treatment preferences for several children’s fractures.

The reasons for the increasing tendency towards operative treatment are multifactorial and patient-, parent- and surgeon-dependent factors as well as technological, economic, social, environmental and legal factors seem to have an impact on this trend.

It is obvious that evidence-based medicine is not the only factor that leads to this tendency. A high level of scientific evidence is currently lacking to support the statement that operative treatment really leads to better long-term outcomes in children’s fractures. Properly designed multicentre clinical trials are needed to determine the best treatment options in many fractures in children.

Cite this article: EFORT Open Rev 2020;5:347-353. DOI: 10.1302/2058-5241.5.200012

Retrospective, multicenter evaluation of complications in the treatment of diaphyseal femur fractures in pediatric patients

INTRODUCTION

Femoral shaft fractures are the commonest major pediatric fractures. For generations, traction and casting were the standard method of treatment for children. However, over the past two decades there has been growing recognition of the advantages of fixation and rapid mobilization.

METHODS

A prospective multicenter study was conducted at four Italian centers of reference for pediatric fractures (January 2005 to December 2014). The study involved 62 patients of both sexes, between 6 and 14 years of age, with closed femoral shaft fractures. The aim was to find out more about the short-term complications of titanium elastic nailing in diaphyseal femur fractures in children in order to reduce them.

RESULTS

The commonest complication observed in our study was pain at the nail entry point (24.19%) due to a local inflammatory reaction. After 1 year, 3.22% had limbs of different lengths. Proximal migration occurred in 1.61% of cases.

DISCUSSION

Over the last two decades, the treatment of femoral shaft fractures in pediatric patients has developed to include internal fixation using Titanium Elastic Nails (TEN). We only observed a few complications in our study, most of which were minor and associated with the surgical technique employed, particularly during the initial phase of the surgeon's learning curve.

CONCLUSIONS

TEN are an excellent internal fixation system if used by an expert surgeon and have a very low rate of complications. None of them produced permanent damage in the patients. In older children weighing more than 50 kg, alternative techniques such as subtrochanteric nailing, plates, or external fixation are advisable.

Locking plate fixation in pediatric femur fracture: evaluation of the outcomes in our experience

Background and Aim: Femoral shaft fracture is a common traumatic musculoskeletal injures in pediatric population. The treatment of diaphyseal femoral fractures depends on age patient and pattern fracture. We present our record about the use of locking plate fixation and their outcomes. Method: We conduct a retrospective analysis in 22 patients, surgically treated for 26 diaphyseal femur fracture between 2008 and 2013. The mean age was 13 years. All the patients underwent a clinical and radiological follow-up for two years. We recorded time to weight bearing, time to union, complication (malalignment, dysmetria, infection), time to resumption to sport, plate removal, parents’ satisfaction. Results: All the patients had a minimal clinical e radiological follow-up of 24 months. The average fracture healing time was of 7.4 weeks. All the patients had a full hip and knee range of movements. Fifteen patients developed minor malalignment (varo-valgus or procurvatum femur) without clinical effects. No cases of infections. The mean time to a full weight bearing was 12 weeks and the return to sportive activity was 24 weeks. Four patients required a plate and screws removal. The average result of parents’ satisfaction was 8/10. Conclusions: Locking plate fixation is to be considered a successful way of treatment for pediatric femur fractures, especially in patients older than 6 years, head-injured or in the treatment of polytrauma. The anatomic and functional outcomes are comparable to those of other fixation techniques for this kind of fracture. (www.actabiomedica.it)

Submuscular plates versus flexible nails in preadolescent diaphyseal femur fractures

PURPOSE

To compare patient characteristics, operative time, estimated blood loss (EBL), postoperative length of hospital stay (LOS) and complications after insertion and removal of submuscular plates (SMPs) versus flexible nails (FNs) for paediatric diaphyseal femur fractures.

METHODS

We reviewed records of 58 children (mean age, 7.7 years SD 2.0) with diaphyseal femur fractures who underwent treatment with SMPs (n = 30) or FNs (n = 28) from 2005 to 2017 (mean follow-up, 22 months SD 28). Patients with pathological fractures or musculoskeletal comorbidities were excluded. Alpha = 0.05.

RESULTS

Insertion of FNs was associated with shorter operative time (ß = -24 mins) and less EBL (ß = -38 mL) (both, p < 0.001) compared with insertion of SMPs, after adjusting for fracture type and time from beginning of study period. Removal of FNs was also associated with shorter operative time (ß = -15 min) compared with removal of SMPs (p < 0.001). EBL during removal was similar between groups (p = 0.080). The FN group had a shorter LOS after insertion (ß = -0.2 d) compared with the SMP group (p = 0.032). Four patients treated with SMPs and three treated with FNs developed surgical site infections. Two patients treated with SMPs and seven treated with FNs experienced implant irritation that resolved with removal. No other complications occurred.

CONCLUSION

Compared with SMPs, FNs were associated with shorter operative time (for insertion and removal), less EBL (for insertion) and shorter post-insertion LOS in patients with diaphyseal femur fractures.

LEVEL OF EVIDENCE

III.

Incidence of deep infection, union and malunion for open diaphyseal femoral shaft fractures treated with IM nailing: A systematic review

BACKGROUND

and purpose: We have undertaken a systematic review to evaluate the clinical results of intramedullary nailing (IMN) for open diaphyseal femoral fractures on the rates of union, delayed union, malunion, superficial and deep infection and bone grafting.

METHODS

We searched the electronic databases of EMBASE, MEDLINE, from their inception until December 1st, 2017 with no language restrictions. The reference lists of all included articles and relevant reviews were also examined for potentially eligible studies. Hand search using electronic database of recent major orthopaedic journals was also carried. Two reviewers working independently extracted study characteristics and data to estimate the diagnostic odds ratio and 95% confidence interval for each result.

RESULTS

Seventeen studies were eligible. Pooled estimate of effect size for union rate was 97% (95% CI: 94-99%). Deep infection rate was 6% (95% CI: 3-9.3%) and more prominent in Gustilo type III injuries; superficial infection was 5.6% (95% CI: 3-9.3%). Delayed union rate 3% (95% CI: 1-5.6%) while, malunion rate was 8.4% (95% CI: 5.7-11.6%). The need for bone grafting ranged from 0 to 9%.

CONCLUSIONS

IMN remains the treatment of choice for open femoral diaphyseal fractures with very good union rates. Gustilo grade III injuries demonstrate a distinct higher deep infection rate and strict adherence to established surgical debridement and fixation protocols is advocated. The need for bone grafting can be as high as 9% and patients should be made aware of the possibility of requiring this additional procedure.

Comparison of three fixation methods in treatment of tibial fracture in adolescents

BACKGROUND

Tibial fractures are the most common musculoskeletal injury in adolescents. The optimal management of tibial fractures in adolescents is controversial. In this study, we compared the outcomes including complications of three fixation methods in tibial fractures of adolescents and explored the factors associated with the complications.

METHODS

A retrospective cohort study about 83 diaphyseal tibial fractures in 79 children and adolescents, who were treated with plate fixation (PF), elastic stable intramedullary nail fixation (ESINF), or external fixation (EF), was conducted. After adjustment for age, weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminution, treatment outcomes were compared in accordance with the length of the hospital stay, time to union, and complication rates including many factors.

RESULTS

The mean age of the patients was 13.4 years, and their mean weight was 44.2 kg. There was a loss of reduction in two of 33 fractures treated with ESINF and four of 13 treated with EF (P < 0.001). At the time of final follow-up, three patients (two treated with EF and one treated with ESINF) had ≥2.0 cm of shortening. Four of the 32 patients (33 fractures) treated with ESINF underwent a reoperation (two due to loss of reduction and one each because of delayed union and nonunion). Six patients treated with EF required a reoperation (four due to loss of reduction, one for malunion and one for replacement of a pin complicated by infection). Two fracture treated with PF required refixation attributing to nonunion and malunion. A multivariate analysis with adjustment for baseline differences showed that EF was associated with a 7.56-times (95% confidence interval 3.74-29.87) greater risk of loss of reduction and/or malunion than ESINF.

CONCLUSIONS

All three treatments had satisfactory outcomes, and EF was correlated with the highest rate of complications in our series of adolescents treated with a tibial fracture. However, we cannot currently recommend that all fractures might be suitable for ESINF. The choice of fixation will remain influenced by surgeon preference in term of expertise and experience, patient and fracture characteristics, and patients and family preferences.

V, RHH A, Khurana A. Current Concepts in Paediatric Femoral Shaft Fractures

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