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MacIsaac MF, Wright JM, Halsey JN, Fitzgerald RE, Snyder CW, Rottgers SA. Management of Pediatric Type III Tibial Shaft Fractures: A Cohort Study Utilizing the Trauma Quality Improvement Program Database. Ann Plast Surg 2024; 93:501-509. [PMID: 39331748 DOI: 10.1097/sap.0000000000004102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2024]
Abstract
BACKGROUND Pediatric open tibial fractures represent a challenging subset of injuries with limited literature to guide management. For children, the epidemiology, management, and outcomes of tibial-shaft fractures have not been fully described. METHODS A retrospective analysis of the Trauma Quality Improvement Program Data Bank from 2017-2020 was used to query demographics, injury patterns, and management strategies in pediatric open tibial fractures. Fractures were compared by age group (0-5, 6-12, 13-17 years) and type (I/II vs type III). A subgroup analysis was performed on patients with type III open fractures. RESULTS A total of 3480 open tibial fractures were identified, 3049 were type I/II, and 431 were type III. Motor vehicle accidents (48%) were the most common mechanism of injury (P < 0.001). Subanalysis of 128 type IIIb/c tibial fractures revealed local flap reconstruction (25%) skin graft (25%), and free tissue transfer were the most common management strategies and soft-tissue coverage was achieved after 162 hours (interquartile range = 109-231). Negative pressure wound therapy was utilized in 63% of cases but used in isolation in only 23% of cases. Immediate fixation with intramedullary nailing was more frequently used in the 13-17 age group while plate fixation was more commonly used in younger age groups. CONCLUSIONS Soft-tissue management patterns following open tibial shaft fractures mirror those seen in adult cohorts. The median time to achieve soft-tissue coverage exceeds the traditional 72-hour target advocated by Godina. Age-based variation is seen in orthopedic management of these fractures based on growth maintenance concerns.
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Affiliation(s)
- Molly F MacIsaac
- From the Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Joshua M Wright
- From the Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Jordan N Halsey
- From the Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | | | - Christopher W Snyder
- Department of Pediatric Surgery, Johns Hopkins All Children's Hospital; St. Petersburg, FL
| | - S Alex Rottgers
- From the Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
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Brinkemper A, Hufnagel SJ, Cibura J, Sträter DM, Cibura C, Schildhauer TA, Kruppa C. Analysis of compartment syndromes in lower extremity pediatric and adolescent trauma - are there predictors of a late onset? Injury 2024; 55:111714. [PMID: 38981358 DOI: 10.1016/j.injury.2024.111714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Revised: 06/21/2024] [Accepted: 06/30/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Purpose of the study was to answer the question, if there are common fracture or injury characteristics, which help to identify patient at risk for a secondary compartment syndrome. MATERIALS AND METHODS Between 2003 and 2022 all children and adolescents who were treated for a traumatic compartment syndrome in a lower extremity were retrospectively evaluated. Patient's demographics were recorded, the underlying trauma mechanism identified. Fractures were classified, treatment and complications were analyzed. We differentiated two groups of patients (early onset vs. late onset) and compared trauma mechanism, fracture location, classification and treatment between those two entities. RESULTS Our collective consisted of 56 children and adolescents with 67 compartment syndromes, with an average age of 14.1 years (5-17). 41 (73.2 %) of the patients were male and 15 (26.8 %) female. Most people in our sample had previously been involved in traffic accidents (64.3 %), with the most common mechanism of injury being "motorbike accident" (34.3 %) and "pedestrian/cyclist accident against car" (26.9 %). There was an accumulation of fractures of the lower leg, in particular tibial shaft fractures (AO 42 and 43A; 49.3 %). In our survey, dislocated fractures and fractures of the foot always led to an early onset of compartment syndrome. The tibial shaft fracture and the surgical treatment with intramedullary nailing showed a significant frequency in the late onset group. CONCLUSIONS Special attention should be paid to pediatric and adolescent patients with tibial shaft fracture and surgical treatment with intramedullary nailing in order to detect and treat a possible late onset of a compartment syndrome at an early stage.
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Affiliation(s)
- Alexis Brinkemper
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-camp Platz 1, 44789, Bochum, Germany.
| | - Silvia Jasmin Hufnagel
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-camp Platz 1, 44789, Bochum, Germany
| | - Jana Cibura
- Orthopaedic Clinic, Klinikum Dortmund gGmbH, Clinic of the University of Witten Herdecke, Beurhausstr. 40, 44137, Dortmund, Germany
| | - Dina Maria Sträter
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Charlotte Cibura
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-camp Platz 1, 44789, Bochum, Germany
| | - Thomas Armin Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-camp Platz 1, 44789, Bochum, Germany
| | - Christiane Kruppa
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil Bochum, Ruhr-University Bochum, Bürkle-de-la-camp Platz 1, 44789, Bochum, Germany
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Landau AJ, Oladeji AK, Cummings JL, Goldstein R, Lin A, Hosseinzadeh P. Outcomes of Elastic Stable Intramedullary Nailing for Surgical Treatment of Pediatric Tibial Shaft Fractures. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202312000-00004. [PMID: 38038594 PMCID: PMC10686583 DOI: 10.5435/jaaosglobal-d-23-00031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND This retrospective study aimed to assess radiographic and clinical outcomes, characterize demographic, injury, and fracture characteristics, and elucidate the rate of postoperative complications and associated factors in a large cohort of children treated with elastic stable intramedullary nail for diaphyseal tibial fractures at two large pediatric referral centers. METHODS Medical records were reviewed for demographic clinical and radiographic parameters at injury, surgery, and all subsequent clinical visits until radiographic healing was observed and/or for a minimum of 6 months postoperatively. RESULTS A total of 146 patients (79.5% male) were included. The mean (SD) age was 11.8 (63.0) years. Radiographic union occurred by 3 months in 56.6% of patients. Nine patients had delayed union, and four had nonunion. By 3 months postoperatively, 97.2% of patients had progressed to full weight bearing and 92.5% had full range of motion of the knee and ankle. Subgroup analyses revealed that patients with open fractures were found to be more than eight times at increased risk of developing delayed union (.6 months, odds ratio = 8.71). CONCLUSION Elastic stable intramedullary nail remains a safe and effective treatment of open and closed pediatric diaphyseal tibial fractures. A small yet notable risk of residual angular deformity, delayed union, and nonunion remains, although rates may be better than previously reported.
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Affiliation(s)
- Andrew J. Landau
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Afolayan K. Oladeji
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Jason L. Cummings
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Rachel Goldstein
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Adrian Lin
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
| | - Pooya Hosseinzadeh
- From the Department of Orthopedic Surgery, Washington University in St. Louis, St. Louis, MO (Dr. Landau, Dr. Oladeji, Dr. Cummings, and Dr. Hosseinzadeh), and the Children's Hospital of Los Angeles, Los Angeles, CA (Dr. Goldstein and Mr. Lin)
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Ahmed N, Kuo YH. Factors associated with compartment syndrome after a tibial fracture in children. Trauma Surg Acute Care Open 2023; 8:e001158. [PMID: 37936901 PMCID: PMC10626752 DOI: 10.1136/tsaco-2023-001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 10/09/2023] [Indexed: 11/09/2023] Open
Abstract
Objectives Compartment syndrome (CS) after a tibial fracture in children is one of the orthopedic emergencies. Identifying high-risk patients in a timely fashion minimizes morbidities. This study aimed to find the risk factors of CS after a tibial fracture. Methods The study data was retrieved from the Trauma Quality Improvement Program database of the calendar year 2017-2019. All patients aged <18 years old who were admitted to the hospital with tibial fractures were included in the study. Patients' characteristics, including demography, injury, injury severity, and associated crushed and vascular injuries were analyzed between the groups who developed CS versus those who did not develop CS after a tibial fracture. Multiple logistic regression analyses were performed to find the association of CS. All p values are two-sided and a p value<0.05 is considered statistically significant. Results Of 4492 patients who qualified for the study, 49 (1.1%) patients developed CS. The patients who developed CS sustained more crush injuries and were associated with a higher rate of vascular injury (2% vs 0.1%, p=0.043% & 10.2% vs 2.2%, p=0.005). Multivariable analysis showed that for every increase in 1 year of age, the odds of occurrence of CS increased by 15.7% (adjusted OR (AOR)=1.157, 95% CI: 1.032 to 1.297, p=0.013). Non-African American race was associated with more than double the risk of developing CS when compared with the African American race, AOR was 2.238, (95% CI: (1.08 to 4.638)). The associated crush injury had an approximately 19-fold higher risk of CS when compared with patients presented with no crush injury, AOR was 18.812, (95% CI: (1.513 to 233.931)). Associated vascular injury was found to have significantly higher AOR, 3.509, 95% CI: (1.287 to 9.563) of CS. Conclusion Increased age, non-African American race, vascular injury, and crushed injury were associated with a risk of developing CS after a tibial fracture. Level of evidence IV Study type: Observational cohort study.
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Affiliation(s)
- Nasim Ahmed
- Department of Surgery, Division of Trauma and Surgical Critical Care, Hackensack Meridian Jersey Shore University Medical Center, Neptune, New Jersey, USA
- Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Yen-Hong Kuo
- Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
- Office of Research Administration, Jersey Shore University Medical Center, Neptune City, New Jersey, USA
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Popa Ș, Ciongradi CI, Sârbu I, Bîcă O, Popa IP, Bulgaru-Iliescu D. Traffic Accidents in Children and Adolescents: A Complex Orthopedic and Medico-Legal Approach. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1446. [PMID: 37761407 PMCID: PMC10527870 DOI: 10.3390/children10091446] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/11/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023]
Abstract
Traffic accidents involving children and adolescents present complex challenges from both the medico-legal and orthopedic standpoints. Despite the implementation of road traffic safety laws, pediatric road traffic injuries continue to be a significant contributor to mortality rates, physical harm, and hospitalization on a global scale. For children and young people, automobile accidents are considered to be the primary culprit of mortality in developed nations. Even in highly developed nations, trauma is a significant factor in infant mortality. Each age category, from childhood to young adulthood, has its fracture patterns, as their skeletons are considerably different from those of adults. The consequences of traffic accidents extend beyond the immediate physical trauma. The medico-legal aspects surrounding these incidents add another layer of complexity, as legal repercussions may affect the responsible adult or parent, particularly in cases involving child fatalities. To effectively address traffic accidents in children and adolescents, a comprehensive approach is necessary. This approach should involve not only medical professionals but also legal experts and policymakers. Collaboration between orthopedic specialists, medico-legal professionals, law enforcement agencies, and relevant government bodies can facilitate the development and implementation of strategies aimed at prevention, education, the enforcement of traffic laws, and improved infrastructure. By addressing both the medical and legal aspects, it is possible to enhance road safety for children and adolescents, reducing the incidence of injuries and their associated long-term consequences. In this review, we aimed to summarize traffic accidents in children and adolescents from a complex orthopedic and medico-legal approach.
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Affiliation(s)
- Ștefan Popa
- 2nd Department of Surgery–Pediatric Surgery and Orthopedics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (Ș.P.); (I.S.); (O.B.)
| | - Carmen Iulia Ciongradi
- 2nd Department of Surgery–Pediatric Surgery and Orthopedics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (Ș.P.); (I.S.); (O.B.)
| | - Ioan Sârbu
- 2nd Department of Surgery–Pediatric Surgery and Orthopedics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (Ș.P.); (I.S.); (O.B.)
| | - Ovidiu Bîcă
- 2nd Department of Surgery–Pediatric Surgery and Orthopedics, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania; (Ș.P.); (I.S.); (O.B.)
| | - Irene Paula Popa
- Department of Physiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania
| | - Diana Bulgaru-Iliescu
- 3rd Department of Medical Specialities–Legal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iași, Romania;
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Chng E, Satkunanantham M, Kang YC, Sechachalam S. Compartment Syndrome following Intramedullary Nail Fixation in Closed Tibial Shaft Fractures. Malays Orthop J 2023; 17:28-34. [PMID: 37583522 PMCID: PMC10425000 DOI: 10.5704/moj.2307.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 12/31/2022] [Indexed: 08/17/2023] Open
Abstract
Introduction Compartment syndrome complicating intramedullary nailing of closed tibia fractures has been described as early as the 1980s, but currently remains less described in literature compared to compartment syndrome directly following trauma. This study aims to review this potentially disabling complication and highlight the importance of timely diagnosis and management of compartment syndrome following fracture fixation, not just after fracture itself, via a review of three cases. Material and methods A retrospective study of a series of three cases was conducted. The type of fracture, wait time to fixation, surgery duration, reaming, size of nail implant used, tourniquet time, and surgical technique were recorded. Time to diagnosis of compartment syndrome, compartment pressure if available, extent of muscle necrosis, reconstructive procedures performed, and post-operative complications were analysed. Results The three cases following high-energy trauma from road traffic accidents presented from January to May 2010. Compartment syndrome was diagnosed clinically for all cases, between one to six days post-operatively and supported by elevated compartment pressure measurements in two of the three cases. Conclusion This study advocates thorough clinical monitoring and maintaining strong clinical suspicion of compartment syndrome in patients even after intramedullary nail fixation of tibial shaft fractures to achieve timely limb-salvaging intervention. While intercompartmental pressure can be used to aid in diagnosis, we do not advise using it in isolation to diagnose compartment syndrome. Tendon transfer improves functional mobility and provides a good result in patients with severe muscle damage, while skin grafting sufficient in patients with minimal muscle damage.
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Affiliation(s)
- E Chng
- Department of General Medicine, Khoo Teck Puat Hospital, Singapore
| | - M Satkunanantham
- Department of Hand and Reconstructive Microsurgery, Tan Tock Seng Hospital, Singapore
| | - Y C Kang
- Department of Hand and Reconstructive Microsurgery, Singapore General Hospital, Singapore
| | - S Sechachalam
- Department of Hand and Reconstructive Microsurgery, Tan Tock Seng Hospital, Singapore
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OBEY MR, SHLYKOV MA, NICKEL KB, KELLER M, HOSSEINZADEH P. Incidence and risk factors for acute compartment syndrome in pediatric tibia fractures. J Pediatr Orthop B 2023; 32:401-404. [PMID: 35502734 PMCID: PMC9630170 DOI: 10.1097/bpb.0000000000000985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute compartment syndrome (ACS) is a rare complication following traumatic injuries in pediatric patients, and tibia fractures represent the most common cause of ACS. To determine the incidence and risk factors of developing ACS, State Inpatient Databases, State Emergency Department Databases, and State Ambulatory Surgery and Services Databases from the Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, were used to retrospectively identify patients 1-18 years of age with tibia fractures from 2006 to 2015 (quarter 3). The HCUP Nationwide Emergency Department Sample for nationwide data was also queried. Multivariable generalized estimating equations models were used to determine risk factors associated with development of ACS. A total of 50 640 patients with tibia fractures were studied, and 309 cases of ACS were identified. The incidence of ACS was 0.6 and 5.5% in the all tibia and open tibia fracture groups, respectively. Twenty-three cases of ACS (7.4% of all ACS) were diagnosed after discharge from the index admission, which was more common in teens treated nonoperatively. Predictors of increased ACS risk in the all tibia fracture group included age 13-18 [relative risk (RR): 4.04)], open fractures (RR: 3.83), and motor vehicle crash (MVC) mechanism (RR: 5.69). Nationwide, open and operatively treated fractures had an increased ACS rate (3.98 and 5.51%, respectively). Teenagers, open fractures, and MVC mechanisms were most strongly associated with ACS. ACS can present in a delayed fashion, as evidenced by postindex cases.
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Affiliation(s)
- Mitchel R. OBEY
- Investigation performed at the St. Louis Children’s Hospital, St. Louis, MO
| | - Maksim A. SHLYKOV
- Investigation performed at the St. Louis Children’s Hospital, St. Louis, MO
| | - Katelin B. NICKEL
- Investigation performed at the St. Louis Children’s Hospital, St. Louis, MO
| | - Matthew KELLER
- Investigation performed at the St. Louis Children’s Hospital, St. Louis, MO
| | - Pooya HOSSEINZADEH
- Investigation performed at the St. Louis Children’s Hospital, St. Louis, MO
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Outcomes and complications following flexible intramedullary nailing for the treatment of tibial fractures in children: a meta-analysis. Arch Orthop Trauma Surg 2022; 142:1469-1482. [PMID: 33635402 DOI: 10.1007/s00402-021-03839-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Tibial shaft fractures are common occurrence in children and surgical treatment is sometimes required, particularly in unstable or open fractures, and in polytrauma. The aim of this study was to investigate the available evidence on the efficacy and safety of flexible intramedullary nailing (FIN) for both open and closed tibia fractures in children, exploring the main surgical outcomes and rate of complications. MATERIALS AND METHODS Pubmed/Medline, Scopus and Cochrane Central databases were searched following the PRISMA guideline. Studies reporting on the outcomes of FIN for paediatric tibia shaft fractures were included. Weighted means were evaluated for surgical outcomes. Meta-analysis of proportion and odd ratios were used to analyse total complication rates and differences between open and closed fractures. RESULTS Twenty-eight studies (835 patients) were included; the mean age was 11.0 ± 3.0 years. The mean follow-up was 22.5 ± 13.5 months; the mean time to full weight-bearing was 7.5 ± 3.7 weeks. The total complication rate was 28.1% (minor = 20.7%, major = 6.3%); this was greater in open fractures (13.6% vs 5.1%, p = 0.007). The rate of union was 97.5%, with a mean time to union of 11.9 ± 7.2 weeks. Malunion was found in 8.5% cases, delayed union in 3.8%, non-union in 1.4%, symptomatic hardware in 5.1%, leg-length discrepancy in 5.0%, superficial infections in 2.3%, deep infections in 1.0%, compartment syndromes in 1.4%, and refracture in 0.2%. Almost all patients returned to unrestricted physical activity. CONCLUSIONS FIN offers excellent outcomes for the treatment of paediatric tibia shaft fractures. Patients presenting with an open fracture have a higher but acceptable complication rate. Comparative studies are needed to clarify if other treatments have superior outcomes.
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Brandes LL, Nicolini LF, Greven J, Lichte P, Stopinski TT, Sattler M, Hildebrand F, Pishnamaz M. Biomechanical Performance of BoneHelix ® Compared with Elastic Stable Intramedullary Nailing (ESIN) in a Pediatric Tibia Fracture Model. Life (Basel) 2021; 11:life11111189. [PMID: 34833065 PMCID: PMC8622329 DOI: 10.3390/life11111189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/31/2021] [Accepted: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
Tibial shaft fractures are common injuries in the pediatric and adolescent populations. Elastic stable intramedullary nailing (ESIN) is the treatment of choice for cases that require surgical stabilization. A new intramedullary device, BoneHelix® (BH), may be an alternative for use with fractures that cannot be satisfactorily stabilized with ESIN. This study aimed to assess the biomechanical performance of BH compared with ESIN in a porcine tibia fracture model, observing cyclic fatigue and load to failure. Computed tomography was used to monitor the implant position and to rule out unintended damage. No implant or bone failure occurred during the fatigue testing. An increase in the cumulative plastic displacement was observed in both test groups over the loading cycles applied. Both implant–bone constructs displayed a trend toward closure of the osteotomy gap. During the load-to-failure test, the average loads at failure in specimens instrumented with ESIN and BH were 5364 N (±723) and 4350 N (±893), respectively, which were not statistically significant (p = 0.11). The values of both groups were two to three times higher than the estimated maximal load (2000 N) during physiological weight bearing. The biomechanical results thus indicate equivalent performance and stability by the implants tested.
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Affiliation(s)
- Laura Leonie Brandes
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany; (L.L.B.); (L.F.N.); (J.G.); (P.L.); (F.H.)
| | - Luis Fernando Nicolini
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany; (L.L.B.); (L.F.N.); (J.G.); (P.L.); (F.H.)
| | - Johannes Greven
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany; (L.L.B.); (L.F.N.); (J.G.); (P.L.); (F.H.)
| | - Philipp Lichte
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany; (L.L.B.); (L.F.N.); (J.G.); (P.L.); (F.H.)
| | - Thomas Thaddäus Stopinski
- Institut für Versuchstierkunde, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany;
| | - Martin Sattler
- Johannes Wesling Klinikum Minden, Hans-Nolte-Straße 1, 32429 Minden, Germany;
| | - Frank Hildebrand
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany; (L.L.B.); (L.F.N.); (J.G.); (P.L.); (F.H.)
| | - Miguel Pishnamaz
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstr. 30, 52074 Aachen, Germany; (L.L.B.); (L.F.N.); (J.G.); (P.L.); (F.H.)
- Correspondence:
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Displaced diaphyseal tibia fractures managed by elastic stable intramedullary nailing with or without the use of intraoperative traction table during nail insertion: a comparative analysis of 160 patients. J Pediatr Orthop B 2021; 30:431-437. [PMID: 32732800 DOI: 10.1097/bpb.0000000000000788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The use of an orthopedic traction table (OTT) during elastic stable intramedullary nailing (ESIN) in the management of displaced diaphyseal tibia fractures (DTFs) is controversial. The aim of this study was to evaluate the clinical and radiological outcome of children with displaced DTF managed by ESIN with and without the use of an OTT. Medical records were retrospectively reviewed for all pediatric patients sustaining DTF managed by ESIN from 2011 to 2019 at two different institutions. In all, 160 consecutive children with displaced DTF were recorded, of whom 80 underwent operative treatment by ESIN without OTT (group A), and 80 by ESIN with the use of an OTT and skeletal traction (group B). ESIN outcome measure scale, Beaty radiologic criteria and Radiographic Union Scale for Tibia fractures (RUST) score were used to evaluate the results. Average patient age at time of injury was 10.8 years (range 7-15). The mean follow-up was 55.8 months (range 12-96). All complications (2.5%) and poorer results according to ESIN outcome measure scale and Beaty radiological criteria were recorded among children managed with OTT. No complications related to pin insertion for skeletal traction were observed. Mean RUST score, length of surgery and cumulative time of radiation exposure were comparable between the two groups. Children with a displaced DTF treated by ESIN without the use of OTT showed superior results as there are no additional procedures (traction wire insertion and removal) decreased theater time and no complications with similar radiation dose.
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Armstrong DG, MacNeille R, Lehman EB, Hennrikus WL. Compartment Syndrome in Children With a Supracondylar Fracture: Not Everyone has Risk Factors. J Orthop Trauma 2021; 35:e298-e303. [PMID: 33252445 DOI: 10.1097/bot.0000000000002030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To clarify the incidence, associated conditions, and timing of fasciotomy for compartment syndrome (CS) in children with a supracondylar (SC) fracture of the humerus. DESIGN A retrospective trauma system database study. SETTING Accredited trauma centers in Pennsylvania. PATIENTS A statewide trauma database was searched for children 2-13 years of age admitted with a SC fracture between January 2001 and December 2015. Four thousand three hundred eight children met inclusion criteria. INTERVENTION Treatment of a SC fracture. MAIN OUTCOME MEASUREMENT Diagnosis of CS/performance of a fasciotomy. RESULTS During the study period, 21 (0.49%) children admitted with a SC fracture of the humerus were treated with fasciotomy. CS/fasciotomy was more likely in males (P = 0.031), those with a nerve injury (P = 0.049), and/or ipsilateral forearm fracture (P < 0.001). Vascular procedure, performed in 18 (0.42%) children, was strongly associated with CS/fasciotomy (P < 0.001). Closed reduction and fixation of a forearm fracture was associated with CS (P = 0.007). Timing of SC fracture treatment did not influence outcome. Fasciotomy was performed subsequent to reduction in 13 subjects; mean interval between procedures was 23.4 hours (r = 4.5-51.3). CONCLUSIONS Risk factors for CS exist; however, they are not required for the condition to develop. CS may develop subsequent to admission and/or SC fracture treatment. In timing of operative management and hospitalization, the results support contemporary practice. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Douglas G Armstrong
- Department of Orthopedics and Rehabilitation, PennState Health Milton S. Hershey Medical Center, Hershey, PA
| | - Rhett MacNeille
- Department of Orthopedic Surgery, Loma Linda University Health, Loma Linda, CA; and
| | - Erik B Lehman
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA
| | - William L Hennrikus
- Department of Orthopedics and Rehabilitation, PennState Health Milton S. Hershey Medical Center, Hershey, PA
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Williams KA, Thier ZT, Mathews CG, Locke MD. Physeal-Sparing Rigid Intramedullary Nailing in Adolescent Tibial Shaft Fractures: A Pilot Study. Cureus 2021; 13:e13893. [PMID: 33880249 PMCID: PMC8046697 DOI: 10.7759/cureus.13893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Purpose: Elastic stable intramedullary nailing (ESIN) and open reduction internal fixation (ORIF) are literature-supported operative treatments for displaced tibial shaft fractures in skeletally immature patients. Very little is written about rigid intramedullary nails (RIMNs) in adolescents. Our purpose is to describe a physeal-sparing, reamed, locked RIMN technique for adolescent tibial shaft fractures and report its safety. Methods: Adolescent patients with tibial shaft fractures indicated for operative intervention at one institution were retrospectively identified from 2011-2018. Patients were classified based on method of fracture fixation. Primary outcomes included fracture union, reoperation, and complication rates. Results: Thirteen patients were included in the RIMN arm, with an average age of 13.8 years. Two patients in the observational group underwent ESIN and seven patients underwent ORIF, with an average age of 11.5 years. Significant differences were found between time of immobilization (28 days vs 121 days), time to touch down weight bearing release (1 day vs 34 days), and hardware pain (2/13 vs 7/9). The RIMN group sustained fewer reoperations (2/13 vs 5/9). No differences were found in rates of complications or fixation failure between groups. Conclusions: Based on our small pilot study, RIMNs in adolescents should be considered as a potential treatment option when a physeal-sparing distal start point is utilized. Additionally, short-term follow-up suggests safety. Patients who underwent the RIMN procedure required fewer reoperations compared with the observational group. Overall, fracture healing was similar across the two groups. The benefits of RIMN include early immobilization and improved weight-bearing profile. Level of Evidence: IV.
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Affiliation(s)
- Kevin A Williams
- Orthopaedic Surgery, University of Alabama at Birmingham School of Medicine, Birmingham, USA
| | - Zachary T Thier
- Medical Education, Lincoln Memorial University DeBusk College of Osteopathic Medicine, Knoxville, USA
| | - Candler G Mathews
- Orthopaedic Surgery, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Mark D Locke
- Orthopaedic Surgery, Prisma Health - University of South Carolina, Columbia, USA
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13
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Stenroos A, Puhakka J, Nietosvaara Y, Kosola J. Treatment of Closed Tibia Shaft Fractures in Children: A Systematic Review and Meta-Analysis. Eur J Pediatr Surg 2020; 30:483-489. [PMID: 31437858 DOI: 10.1055/s-0039-1693991] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Tibia fractures are among the most common long-bone fractures in children. Despite this, there is no current consensus on the optimal treatment strategy for closed displaced tibia shaft fractures in the pediatric patient population. The aim of this study is to compare the reported complications and outcomes of reduction and cast immobilization versus flexible intramedullary nailing in the treatment of pediatric tibia shaft fractures. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement when conducting and reporting this prospectively registered systematic review. Eleven studies were included. Quality of the studies was assessed using the Coleman methodology score. Mantel-Haenszel cumulative odds ratios were used to compare the risk of complication between different methods of treatment. Eleven studies including 1,083 patients with diaphyseal fractures of the tibia met the inclusion criteria. The most common fracture type was simple 42-A (782; 91%). Majority (75%) of the patients were treated nonoperatively. The total complication rate was higher among operatively treated patients (24 vs. 9%; p < 0.05). Satisfactory fracture alignment had to be restored surgically in 5% of the primarily nonoperatively treated patients. The evidence levels of the included studies were II (1), III (2), and IV (7). Three-fourths of closed diaphyseal fractures of the tibia in children are still treated with reduction and cast immobilization. Flexible intramedullary nailing is associated with significantly higher complication rate than nonoperative treatment.
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Affiliation(s)
- Antti Stenroos
- Department of Orthopedics and Traumatology, Töölö Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Jani Puhakka
- Department of Orthopedics and Traumatology, Töölö Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Yrjänä Nietosvaara
- Department of Orthopaedic Surgery, Helsingin yliopisto Lasten ja nuorten klinikka, Helsinki, Finland
| | - Jussi Kosola
- Department of Orthopedics and Traumatology, Töölö Hospital, Helsinki University Hospital, Helsinki, Finland
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Risk Factors for Adverse Radiographic Outcomes After Elastic Stable Intramedullary Nailing of Unstable Diaphyseal Tibia Fractures in Children. J Pediatr Orthop 2020; 40:481-486. [PMID: 32282621 DOI: 10.1097/bpo.0000000000001565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Elastic stable intramedullary nails (ESIN) are commonly utilized to treat unstable pediatric tibia fractures but have been associated with complications. The purpose of this study was to identify risk factors for adverse radiographic outcomes after ESIN of pediatric tibia fractures. METHODS A retrospective review of all patients who underwent diaphyseal tibia fracture stabilization with ESIN between 2010 and 2018 at 3 pediatric level 1 trauma centers was performed. Inclusion criteria were open growth plates, no intra-articular or physeal fracture involvement, and radiographic follow-up until union. Patient demographics, injury mechanism, fracture characteristics, and implant fill relative to the medullary canal were recorded. Radiographic outcome measures included achievement of and time to union, residual angular deformity, and additional procedures. RESULTS One hundred seventy-two patients met inclusion criteria and were followed for a mean of 1.2 years. Nonunions were observed in 3% of the patient cohort. Another 10% required >6 months to heal, but did not require further surgical intervention. Angular deformities were common with 57% having a residual deformity ≥5 degrees and 14% having a residual deformity ≥10 degrees. Of the patients with a residual deformity between 5 and 10 degrees, 3% were symptomatic, where as 26% of the patients with a residual deformity ≥10 degrees were symptomatic. Greater angular deformities were associated with open fractures, compartment syndrome, and longer time to union. Patient age, weight, tibial comminution, and canal fill were not associated with nonunions or malunions. CONCLUSIONS ESIN of pediatric tibia fractures results in reliable healing for a majority of patients, but poses risks for residual angular deformities and delayed healing. Open fractures and compartment syndrome were associated with adverse radiographic outcomes.
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Quadruple Versus Double Flexible Intramedullary Nails to Treat Pediatric Distal-third Tibial Shaft Fractures: A Biomechanical Comparison. J Pediatr Orthop 2020; 40:487-491. [PMID: 32931690 DOI: 10.1097/bpo.0000000000001604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The vast majority of pediatric distal-third tibial shaft fractures can be treated with closed reduction and casting. If conservative measures fail, then these fractures are usually treated with 2 antegrade flexible intramedullary nails. A postoperative cast is usually applied because of the tenuous fixation of the 2 nails. Recent studies have described the use of 4 nails to increase the stability of the fixation, a technique that may preclude the need for postoperative casting. The purpose of this biomechanical study is to quantify the relative increase in stiffness and load to failure when using 4 versus 2 nails to surgically stabilize these fractures. METHODS Short, oblique osteotomies were created in the distal third of small fourth-generation tibial sawbones and stabilized with 2 (double) or 4 (quadruple) flexible intramedullary nails. After pilot testing, 5 models per fixation method were tested cyclically in axial compression, torsion, and 4-point bending in valgus and recurvatum. At the end of the study, each model was loaded to failure in valgus. Stiffness values were calculated, and yield points were recorded. The data were compared using Student's t tests. Results are presented as mean±SD. The level of significance was set at P≤0.05. RESULTS Stiffness in valgus 4-point bending was 624±231 and 336±162 N/mm in the quadruple-nail and double-nail groups, respectively (P=0.04). There were no statistically significant differences in any other mode of testing. CONCLUSIONS The quadruple-nail construct was almost 2 times as stiff as the double-nail construct in resisting valgus deformation. This provides biomechanical support for a previously published study describing the clinical success of this fixation construct.
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Do Patient-specific or Fracture-specific Factors Predict the Development of Acute Compartment Syndrome After Pediatric Tibial Shaft Fractures? J Pediatr Orthop 2020; 40:e193-e197. [PMID: 31157755 DOI: 10.1097/bpo.0000000000001410] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Tibial shaft fractures are the most common injuries preceding acute compartment syndrome (ACS), so it is important to understand the incidence of and risk factors for ACS after pediatric tibial shaft fractures. The purposes of this study were to determine the rate at which ACS occurs and if any patient or fracture characteristics are significantly associated with developing ACS. METHODS All patients aged 5 to 17 years treated for a tibial shaft fracture at a level 1 pediatric trauma center, a level 1 adult trauma center, and an outpatient orthopaedic practice between 2008 and 2016 were retrospectively identified. Demographics, mechanisms of injury, and fracture characteristics were collected from the medical records. Radiographs were reviewed by study authors. ACS was diagnosed clinically or by intracompartmental pressure measurement. Univariable analysis was performed using the Fisher exact test for nominal variables and simple logistic regression for continuous variables. Multivariable analysis was performed using stepwise logistic regression. RESULTS Among 515 patients with 517 tibial shaft fractures, 9 patients (1.7%) with 10 (1.9%) fractures developed ACS at a mean age of 15.2 years compared with a mean age of 11 years in patients without ACS (P=0.001). One patient with bilateral tibial fractures developed ACS bilaterally. Age greater than 14 years (P=0.006), higher body mass index (P<0.001), motorcycle or motor vehicle accidents (P=0.034), comminuted and segmental tibial shaft fractures (P<0.001), ipsilateral fibular fracture (P=0.002), and associated orthopaedic injuries (P=0.032) were all significantly more common in the ACS group. CONCLUSIONS ACS developed in 1.7% of the patients with tibial shaft fractures in this retrospective study-a rate significantly lower than previously reported. Age greater than 14 years, higher body mass index, motor vehicle or motorcycle accidents, comminuted or segmental fracture pattern, ipsilateral fibular fracture, and associated orthopaedic injuries are all significantly associated with its development. LEVELS OF EVIDENCE Level III-retrospective comparative study.
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17
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Abstract
Diaphyseal tibia fractures in the pediatric population have dynamic treatment strategies that depend on injury pattern, mechanism, patient skeletal maturity and size. Treatment strategies include closed reduction and cast immobilization, flexible nails, uniplanar or multiplanar external fixation or plate osteosynthesis. Accepted parameters for sagittal and coronal alignment vary based on age and potential for remodeling, although all fractures should have minimal rotational malalignment and less than 1 cm of shortening. Stable union generally occurs in 3 to 4 weeks for the common toddler's fracture and 6 to 8 weeks in other fracture patterns. Complications such as compartment syndrome are possible with both open and closed injuries, and nonunions, although rare, are more common in patients treated with external fixation or flexible nailing. Overall, treatment should be predicated on a full evaluation of the patient, fracture, local soft tissues, and any concomitant injuries.
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18
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Treatment of Unstable Pediatric Tibial Shaft Fractures with Titanium Elastic Nails. ACTA ACUST UNITED AC 2019; 55:medicina55060266. [PMID: 31185694 PMCID: PMC6630376 DOI: 10.3390/medicina55060266] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/25/2019] [Accepted: 06/08/2019] [Indexed: 01/29/2023]
Abstract
Background and objectives: Pediatric tibial shaft fractures often have satisfactory outcomes after closed reduction and casting. However, surgical treatment may be required in unstable or open fractures. Titanium elastic nails (TENs) are a good option for the surgical treatment of pediatric tibial fractures due to their advantages such as short hospitalization periods, easy applicability, early weight bearing, and early union. In this study, we evaluated radiological and functional outcomes in pediatric patients with tibial shaft fractures that underwent fixation with TENs. Materials and methods: A total of twenty tibial shaft fractures that were treated with TENs in our clinic between 2013 and 2017 were retrospectively reviewed. The mean age at injury was 8.9 ± 2.78 (range of 3–14) years. Seven (35%) out of 20 fractures were open fractures, of which one fracture was classified as Grade I and six fractures were classified as Grade II. In each patient, antegrade nailing was performed by inserting a TEN in the medial and another TEN in the lateral side of the proximal metaphysis. Clinical outcomes including union, alignment, leg-length inequality, and complications were evaluated using modified Flynn’s criteria. Results: The mean time to union was 10.85 ± 3.39 (range of 6–20) weeks. No patient had a sagittal or coronal angulation of over 10°. One patient had a leg-length inequality of 10 mm. Among three patients with open fractures, two of them had superficial wound infections and the other patient had a deep wound infection. All the infections were successfully treated with appropriate antibiotic therapies. Four other patients had pin tract irritation that required no intervention. No significant difference was observed between patients with open and closed fractures with regard to the clinical and radiological findings although patients with open fractures had a significantly higher complication rate compared to patients with closed fractures (p < 0.05). No patient had a restricted range of motion of the ankle and knee joints. Twelve (60%) patients had an excellent outcome, and eight (40%) patients had a satisfactory outcome. Conclusions: Intramedullary fixation with TENs provides favorable outcomes and reduced complication rates in the treatment of unstable pediatric tibial shaft fractures that cannot be reduced with conservative treatment modalities or cannot be casted due to the presence of an edema or open wound.
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19
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Andreacchio A, Alberghina F, Marengo L, Canavese F. Pediatric tibia and femur fractures in patients weighing more than 50 kg (110 lb): mini-review on current treatment options and outcome. Musculoskelet Surg 2019; 103:23-30. [PMID: 30311075 DOI: 10.1007/s12306-018-0570-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 10/06/2018] [Indexed: 06/08/2023]
Abstract
The main objective of this paper is to review the current literature on treatment of tibial and femur fractures in children and adolescents guided by body weight in patients weighing 50 kg (110 lb) or more. A secondary aim of this mini-review was to determine, as per literature review, whether weight > 50 kg (110 lb) is an identifiable factor associated with increased complication rate. A search of the PubMed/MEDLINE, EMBASE and Cochrane Database of Systematic Reviews databases from 1954 to September 2017 was performed to identify papers related to pediatric tibia and femur fractures in children weighing more than 50 kg (110 lb). Abstracts were screened, and relevant full-text articles were retrieved for further review. Reference sections of identified papers were also screened to identify further literature. All levels of evidence were included. Overall, seven full-text articles dealing with pediatric tibia or femur fractures in patients weighing more than 50 kg (110 lb), and one article reporting on both femur and tibia fractures in this patients' population, have been identified (n = 8 full-text article included). The articles reviewed a total of 679 children. In particular, 48/438 femur shaft fractures (mean weight: 51.7 kg or 113.9 lb) and 91/241 tibia fractures (mean weight: 53.3 kg or 117.5 lb) met the inclusion criteria. The overall rate of complications was 27.9%. In particular, the rate of complication was 51.7 and 29.6% in children with femur and tibia fracture weighing more than 50 kg (110 lb), respectively (p < 0.05). Elastic stable intramedullary nailing (ESIN) has become the treatment of choice for displaced tibia and femur shaft fractures in children between six and 12-15 years of age. Unstable fracture pattern, higher age and higher weight have been reported as potential risk factors associated with poor outcomes in children and adolescents treated with ESIN for displaced long bone fractures of the lower extremity, in particular femur shaft fractures. Despite these findings, data reporting exclusively on ESIN-treated long bone fractures in children weighing 50 kg (110 lb) or more remain scant.
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Affiliation(s)
- A Andreacchio
- Department of Pediatric Orthopaedic Surgery, Regina Margherita Children's Hospital, Piazza Polonia 94, 10126, Turin, Italy
| | - F Alberghina
- Department of Pediatric Orthopaedic Surgery, Regina Margherita Children's Hospital, Piazza Polonia 94, 10126, Turin, Italy.
| | - L Marengo
- Department of Pediatric Surgery, University Hospital Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France
| | - F Canavese
- Department of Pediatric Surgery, University Hospital Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand, France
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Cruz AI, Raducha JE, Swarup I, Schachne JM, Fabricant PD. Evidence-based update on the surgical treatment of pediatric tibial shaft fractures. Curr Opin Pediatr 2019; 31:92-102. [PMID: 30461511 DOI: 10.1097/mop.0000000000000704] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To describe surgical treatment options for pediatric tibial shaft fractures which are the third most common pediatric long bone fracture. Management of these injuries is dictated by fracture location, fracture pattern, associated injuries, skeletal maturity, and other patient-specific factors. Although most pediatric tibial shaft fractures can be treated nonoperatively, this review provides an update on surgical treatment options when operative intervention is indicated. RECENT FINDINGS Advances in surgical implants and techniques affords a wide range of options for the surgical treatment of pediatric tibial shaft fractures. Flexible intramedullary nailing is gaining wide adoption for acute surgical treatment. Recent studies support cross-sectional imaging for further evaluation and scrutiny of fracture patterns suspicious for intraphyseal or intra-articular extension. Grade I open tibial shaft fractures may be safely treated with irrigation and debridement in the emergency department; however, no high-level comparative studies have been performed to make any definitive conclusions regarding the effectiveness of this treatment strategy. SUMMARY Tibial shaft fractures are common injuries in pediatric patients. Management is dictated by fracture location, fracture pattern, associated injuries, patient age, and other patient-specific factors. Surgical intervention is indicated for fractures that are open, irreducible, have failed nonoperative management, are associated with compartment syndrome, or in the multiply injured patient. Surgical treatment options include flexible intramedullary nailing, plate osteosynthesis, external fixation, and rigid intramedullary nailing. Recent literature has shown increased rates of flexible intramedullary nailing. All operative and nonoperative management options can result in complications including compartment syndrome, infection, delayed union, nonunion, malunion, limb length discrepancy, and symptomatic hardware. Most pediatric patients go on to uneventful union with excellent final outcomes and return to full activities.
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Affiliation(s)
- Aristides I Cruz
- Department of Orthopaedic Surgery, Hasbro Children's Hospital, Warren Alpert Medical School of Brown University
| | - Jeremy E Raducha
- Department of Orthopaedic Surgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Ishaan Swarup
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Jonathan M Schachne
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Peter D Fabricant
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York, USA
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Raducha JE, Swarup I, Schachne JM, Cruz AI, Fabricant PD. Tibial Shaft Fractures in Children and Adolescents. JBJS Rev 2019; 7:e4. [DOI: 10.2106/jbjs.rvw.18.00047] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Lim KBL, Laine T, Chooi JY, Lye WK, Lee BJY, Narayanan UG. Early morbidity associated with fasciotomies for acute compartment syndrome in children. J Child Orthop 2018; 12:480-487. [PMID: 30294372 PMCID: PMC6169567 DOI: 10.1302/1863-2548.12.180049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Acute compartment syndrome (ACS) requires urgent fasciotomy to decompress the relevant muscle compartment/s prior to onset of irreversible myonecrosis and nerve injury. A fasciotomy is not a benign procedure. This study aims to describe and quantify early morbidity directly associated with fasciotomies for ACS in children. METHODS Clinical charts of 104 children who underwent 112 fasciotomies over a 13-year period at a tertiary children's hospital were reviewed. The following were analyzed: ACS aetiology, fasciotomy site, number of subsequent procedures, method of wound closure, short-term complications and length of hospital stay. RESULTS Short-term complications included wound infections (6.7%) and the need for blood transfusion (7.7%). Median number of additional operations for wound closure was two (0 to 10) and median inpatient stay was 12 days (3 to 63; SD 11.7). After three unsuccessful attempts at primary closure, likelihood of needing skin grafting for coverage exceeded 80%. Analyses showed that fasciotomy-wound infections were associated with higher risk for four or more closure procedures. Number of procedures required for wound closure correlated with longer inpatient stay as did ACS associated with non-orthopaedic causes. CONCLUSION Fasciotomy is associated with significant early morbidity, the need for multiple closure operations, and prolonged hospital stay. The decision for fasciotomy needs careful consideration to avoid unnecessary fasciotomies, without increasing the risk of permanent injury from missed or delayed diagnosis. Skin grafting should be considered after three unsuccessful closure attempts. Less invasive tests or continuous monitoring (for high-risk patients) for compartment syndrome may help reduce unnecessary fasciotomies. LEVEL OF EVIDENCE Level IV, Case series.
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Affiliation(s)
- K. B. L. Lim
- Department of Orthopaedic Surgery & Division of Surgery, KK Women’s & Children’s Hospital, Singapore, Singapore, Correspondence should be sent to K. Lim, Division of Surgery, Executive Office, KK Women’s & Children’s Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore. E-mail:
| | - T. Laine
- Department of Orthopedics, Institute of Clinical Sciences, Sahlgrenska University Hospital and Sahlgrenska Academy, Gothenburg, Sweden
| | - J. Y. Chooi
- Duke-NUS Medical School, Singapore, Singapore
| | - W. K. Lye
- Duke-NUS Medical School, Singapore, Singapore,Centre for Quantitative Medicine, Office of Clinical Sciences, Duke-NUS Medical School, Singapore, Singapore
| | - B. J. Y. Lee
- Department of Orthopaedic Surgery & Division of Surgery, KK Women’s & Children’s Hospital, Singapore, Singapore
| | - U. G. Narayanan
- Divisions of Orthopaedic Surgery & Child Health Evaluative Sciences, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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Abstract
BACKGROUND Skeletal trauma is a primary tenet of pediatric orthopaedics. Many high-quality studies have been published over the last few years with substantial relevance to the clinical practice of pediatric orthopaedic trauma. Because of the volume of literature on the subject, this review excludes upper extremity trauma and focuses on the publications affecting the lower extremity. METHODS An electronic search of the PubMed database was performed utilizing keywords for pediatric lower extremity trauma: pelvic injuries, femur fractures, tibial shaft fractures, femur fractures, ankle fractures, and foot fractures. All 835 papers related to the treatment of pediatric orthopaedic trauma of the lower extremity published from January 1, 2012 to July 31, 2017 were reviewed, yielding 25 papers that were believed to contribute significant findings to the profession. RESULTS Of the 25 papers selected for presentation within this review, 8 related to tibial shaft injuries, 6 involved the pelvis, 5 involved femur fractures, 4 related to ankle injuries, 2 involved foot injuries, and 1 regarding trauma and venous thromoembolism. The level of evidence for these studies were either level III or IV. CONCLUSIONS Higher-grade pediatric pelvic fractures do not correlate with increased severity of splenic or hepatic injuries. Successful union of femur fractures in older children can be obtained by surgeon preferred method of surgical management. Pediatric tibia shaft fractures should be managed conservatively in most cases; however, fractures with >20% of displacement and associated fibula fractures have a 40% risk of requiring delayed surgical stabilization. Vigilance remains the sin qua non regarding identification and appropriate management of compartment syndrome and venous thromboemobolism in children. Many Salter-Harris I distal fibula fractures are now believed to be ligamentous injury and can be treated as such. Calcaneous fractures remain uncommon in pediatrics, but minimally invasive approaches of surgical reduction and fixation may reduce complications in management. LEVEL OF EVIDENCE Level IV.
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Simon AL, Apostolou N, Vidal C, Ferrero E, Mazda K, Ilharreborde B. Paediatric tibial shaft fractures treated by open reduction and stabilization with monolateral external fixation. J Child Orthop 2018; 12:20-28. [PMID: 29456750 PMCID: PMC5813121 DOI: 10.1302/1863-2548.12.170056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Elastic stable intramedullary nailing is increasingly used for surgical treatment of tibial shaft fractures, but frequently requires immobilization and delayed full weight-bearing. Therefore, external fixation remains interesting. The aim was to report clinico-radiological outcomes of monolateral external fixation for displaced and unstable tibial shaft fractures in children. METHODS All tibial fractures consecutively treated by monolateral external fixation between 2008 and 2013 were followed. Inclusion criteria included skeletal immaturity and closed and open Gustilo I fractures caused by a direct impact. Patients were seen until two years postoperatively. Demographics, mechanism of injury, surgical data and complications were recorded. Anteroposterior and lateral side radiographs were performed at each visit. Full-limb 3D reconstructions using biplanar stereroradiography was performed for final limb length and alignment measures. RESULTS A total of 45 patients (mean age 9.7 years ± 0.5) were included. In all, 17 were Gustilo I fractures, with no difference between open and closed fractures for any data. Mean time to full weight bearing was 18.2 days ± 0.7. After 15 days, 39 patients returned to school. Hardware removal (mean time to union 15.6 weeks ± 0.8) was performed during consultation under analgesic gas. There were no cases of nonunion. No fracture healed with > 10° of angulation (mean 5.1° ± 0.4°). Leg-length discrepancy > 10 mm was found for six patients. CONCLUSIONS This procedure can be a safe and simple surgical treatment for children with tibial shaft fractures. Few complications and early return to school were reported, with the limitations of non-comparative study. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- A.-L. Simon
- Pediatric Orthopedic Department, Robert Debré Hospital, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Diderot University, Paris, France,
Correspondence should be sent to A-L. Simon, Pediatric Orthopedic Department, Robert Debré Hospital, AP-HP, Paris Diderot University, 48 Bd Sérurier, 75019 Paris, France. E-mail:
| | - N. Apostolou
- Pediatric Orthopedic Department, Robert Debré Hospital, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Diderot University, Paris, France
| | - C. Vidal
- Pediatric Orthopedic Department, Robert Debré Hospital, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Diderot University, Paris, France
| | - E. Ferrero
- Pediatric Orthopedic Department, Robert Debré Hospital, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Diderot University, Paris, France
| | - K. Mazda
- Pediatric Orthopedic Department, Robert Debré Hospital, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Diderot University, Paris, France
| | - B. Ilharreborde
- Pediatric Orthopedic Department, Robert Debré Hospital, Assistance Publique- Hôpitaux de Paris (AP-HP), Paris Diderot University, Paris, France
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25
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Abstract
Pediatric acute compartment syndrome (PACS) is a clinical entity that must be carefully differentiated from the adult version (ie, acute compartment syndrome). Healthcare providers must understand the variable etiologies of PACS, of which trauma is the most common but can also include vascular insult, infection, surgical positioning, neonatal phenomena, overexertion, and snake and insect bites. In addition to the unique etiologies of PACS, providers must also recognize the different signs and symptoms of PACS. The three As (ie, anxiety, agitation, analgesic requirement) of PACS have supplanted the classic adult signs as being more accurate and allowing earlier detection. In children with questionable clinical signs but concern for PACS, compartment pressure measurement may be necessary to confirm the diagnosis. Overall, outcomes after fasciotomy in children tend to be excellent; however, diagnostic delays secondary to unfamiliar clinical scenarios can lead to myonecrosis and subsequent poor outcomes.
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Tibia Shaft Fractures in Adolescents: How and When Can They be Managed Successfully With Cast Treatment? J Pediatr Orthop 2016; 36 Suppl 1:S15-8. [PMID: 27078230 DOI: 10.1097/bpo.0000000000000762] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Despite the increasing popularity of operative treatment in adolescent tibia fractures, casting remains a viable first-line treatment. Because the selection bias in published reports does not allow direct comparison between casting and flexible nail treatment of closed pediatric tibia fractures, it is unclear whether flexible nailing offers any advantages over casting. This overview discusses parameters of acceptable alignment, indications, techniques for successful reduction and casting, subsequent inpatient and outpatient management including wedging of casted tibia fractures, expected outcomes, and comparison of casting with flexible nailing. As with any orthopaedic procedure, careful attention to patient selection, indications, and detail facilitates successful cast treatment in this older pediatric population.
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27
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Flexible Intramedullary Nailing of Unstable and/or Open Tibia Shaft Fractures in the Pediatric Population. J Pediatr Orthop 2016; 36 Suppl 1:S19-23. [PMID: 27078231 DOI: 10.1097/bpo.0000000000000754] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Tibial shaft fractures are common injuries in the pediatric population, and can be treated conservatively the vast majority of the time. Yet, it is important to recognize that open and/or unstable tibial shaft fractures represent a different entity. Rigid intramedullary devices are generally contraindicated because of the skeletal immaturity of these patients, and external fixation is associated with a high complication rate. As a result, flexible nailing is being utilized with increasing frequency. It is essential for the clinician to understand the pearls and pitfalls associated with the utilization of these flexible nails; particularly in regards to their immediate use in the context of open fractures and the risk of compartment syndrome postoperatively after fixation.
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28
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Brantley J, Majumdar A, Jobe JT, Kallur A, Salas C. A Biomechanical Comparison Of Pin Configurations Used For Percutaneous Pinning Of Distal Tibia Fractures In Children. THE IOWA ORTHOPAEDIC JOURNAL 2016; 36:133-137. [PMID: 27528850 PMCID: PMC4910788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Percutaneous pin fixation is often used in conjunction with closed-reduction and cast immobilization to treat pediatric distal tibia fractures. The goal of this procedure is to maintain reduction and provide improved stabilization, in effort to facilitate a more anatomic union. We conducted a biomechanical study of the torsional and bending stability of three commonly used pin configurations in distal tibia fracture fixation. METHODS A transverse fracture was simulated at the metaphyseal/diaphyseal junction in 15 synthetic tibias. Each fracture was reduced and fixed with two Kirschner wires, arranged in one of three pin configurations: parallel, retrograde, medial to lateral pins entering at the medial malleolus distal to the fracture (group A); parallel, antegrade, medial to lateral pins entering at the medial diaphysis proximal to the fracture (group B); or a cross-pin configuration with one retrograde, medial to lateral pin entering the medial malleolus distal to the fracture and the second an antegrade, medial to lateral pin entering at the medial diaphysis proximal to the fracture (group C). Stability of each construct was assessed by resistance to torsion and bending. RESULTS Resistance to external rotation stress was significantly higher in group A than group B (P = 0.044). Resistance to internal rotation stress was significantly higher in group C than group B (P = 0.003). There was no significant difference in torsional stiffness when comparing group A with group C. Under a medial-directed load, group B and C specimens were significantly stiffer than those in group A (28 N/mm and 24 N/mm vs. 14 N/mm for A; P = 0.001 and P = 0.009, respectively). CONCLUSIONS None of the three pin configurations produced superior results with respect to all variables studied. Group A configuration provided the highest resistance to external rotation forces, which is the most clinically relevant variable under short-cast immobilization. Parallel, retrograde, medial to lateral pins entering at the medial malleolus provide the greatest resistance to external rotation of the foot while minimizing the potential for iatrogenic injury to soft tissue structures.
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Affiliation(s)
- Justin Brantley
- Department of Orthopaedics & Rehabilitation
- Center for Biomedical Engineering
| | | | | | | | - Christina Salas
- Department of Orthopaedics & Rehabilitation
- Center for Biomedical Engineering
- Department of Mechanical Engineering, University of New Mexico, Albuquerque, NM
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29
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Abstract
This study retrospectively analyzed cast treatment of 75 adolescent closed tibial diaphyseal fractures. The average age was 13.3 years (range, 10-17.4 years). Of the patients, 21% (16/75) required cast change/wedging in the clinic for loss of reduction, and three patients (4%, 3/75) injured in vehicular collisions had failure of cast treatment, requiring an unplanned surgical intervention. Initial and immediate postreduction radiographic deformities were greater (P<0.05) in patients who required cast change/wedging. Of the patients, 59% (44/75) required over 3 months of cast immobilization. Casting is successful in the majority of adolescent patients despite prolonged immobilization and the need for cast change/wedging.
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