Algorithm for the management of femoral shaft fractures in children

Elastic stable intramedullary nail fixation versus submuscular plate fixation of pediatric femur shaft fractures in school age patients: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Studies of clinical outcomes that compare the elastic stable intramedullary nail (ESIN) with the submuscular plate (SMP) were controversial. The meta-analysis was performed to summarize existing evidence, aiming to determine whether ESIN was superior to SMP in pediatric femur shaft fractures.

METHODS

Search strategies followed the recommendations of the Cochrane collaboration. Electronic searches such as PubMed, Embase, Web of Science, Cochrane were systematically searched for publications concerning ESIN and SMP from the inception date to March 2023. Two investigators independently searched, screened, and reviewed the full text of the article. Disagreements generated throughout the process were resolved by consensus, and if divergences remain, they were arbitrated by a third author.

RESULTS

This study included 8 articles, comprising a total of 561 patients with a similar baseline. Compared to the SMP, the ESIN had shorter operation time (mean difference = -16.16; 95% CI = -22.83 to -9.48, P < .00001), and less intraoperative blood loss (mean difference = -53.62; 95% CI = -58.89 to -48.36, P < .00001), but had a higher incidence of implant irritation (odds ratio [OR] = 6.49; 95% CI = 3.01 to 13.98, P < .0001), lower limb malalignment (OR = 2.60; 95% CI = 1.12 to 6.04, P = .96) and overall complications(OR = 4.14; 95% CI = 2.51 to 6.84, P < .0001). And there was no significant difference in radiation time, length of hospital stay, limb length discrepancy, infection rate, delayed union rate and unplanned revised surgery rate (P > .05).

CONCLUSIONS

Compared to the SMP, the ESIN offers shorter operative time, and less blood loss. However, the SMP is superior to ESINs in complication rates, especially regarding implant irritation and malalignment. Both methods could achieve excellent satisfactory functional outcomes. Thus, the SMP is an alternative choice in the pediatric femur shaft fracture.

Adult Proximal Humeral Locking Plate Is a Good Alternative Option in the Treatment of Adolescent Subtrochanteric Femur Fractures: A Case Series and Literature Review

Purpose

Management of pediatric subtrochanteric femur fractures (SFFs) is difficult. The aim of this study was to evaluate the outcomes of adolescent SFFs treated with adult proximal humeral locking plates (PHLPs).

Materials and Methods

A retrospective analysis of 18 adolescents (11 male, 7 female) with a diagnosis of SFF who underwent internal fixation with a PHLP was conducted. Data regarding injury mechanism, fracture pattern, and time to union were recorded for all patients. In addition, a clinical and functional evaluation of patients was performed using the Harris hip score (HHS), Iowa hip score (IHS), modified Merle d'Aubigne-Postel score (MMAPS), Flynn criteria, and hip range of motion (ROM).

Results

The mean age of the patients was 12.72±2.05 years (range, 10-16 years). Radiological observation was performed for evaluation of five different injury mechanisms and different fracture patterns in patients. The mean postoperative HHS was 92.27±5.61, the mean IHS was 90.88±6.46, and the mean MMAPS was 17.22±0.94. According to the Flynn criteria, excellent results were achieved in 14 cases and satisfactory results were obtained in four cases. Measurements of the patients' mean hip ROM values were as follows: 17.77±3.52° in extension, 115.27±6.74° in flexion, 43.05±3.48° in abduction, 27.50±4.28° in adduction, 42.22±4.60° in internal rotation, and 42.22±3.91° in external rotation.

Conclusion

Surgery performed on adolescent patients using an adult PHLP showed good, safe results. Therefore, it should be considered as an alternative option.

Therapy preference of 131 parents confronted with a pediatric femoral fracture

BACKGROUND

The management of femoral fractures in children between 3 and 5 years of age is still vividly debated. Therefore, we aimed to assess the basic attitude of parents if confronted with a hypothetical femoral fracture of their toddler.

MATERIALS AND METHODS

Parents of children aged between 12 and 36 months were asked for their preference after receiving detailed information on conservative and surgical treatment of femoral shaft fractures. Furthermore, we obtained information regarding the parents' gender, marital status, medical background, highest level of education and profession in a leading or non-leading position and if any of their children already had undergone any operations. The Freiburg Personality Inventory (FPI-R) questionnaire was used to assess parents' personality traits.

RESULTS

In total, 131 participants were included in this study. The vast majority (n = 116, 88.5%) preferred surgical treatment. The most frequently mentioned reasons for this decision were lack of acceptance, followed by faster reconvalescence, shorter hospital stay, less deformity or growth disorders and less stress on the child. The only reason stated against surgical treatment was the need of general anesthesia. A significantly higher rate of conservative procedures was noticed in self-employed participants and stress was found to significantly influence the treatment decision of the parents toward conservative treatment.

CONCLUSION

The majority of parents confronted with a hypothetical femoral fracture of their child questioned in this study opted for a surgical approach with elastic stable intramedullary nailing (ESIN). This corresponds with trends toward surgery in these cases in major trauma centers in Europe.

Pediatric Femoral Shaft Fracture: An Age-Based Treatment Algorithm

PURPOSE

Fractures of the femoral shaft in children are common. The rates of bone growth and remodeling in children vary according to their ages, which affect their respective management.

METHODS

This paper evaluates the incidence and patterns of pediatric femoral shaft fracture and the current concepts of treatments available.

RESULTS

The type of fracture-closed or open; stable or unstable-needs to be taken into account. Child abuse should be suspected in fractures sustained by infants. For younger children, non-surgical management is preferred, which include Pavlik harness (< 6 months old) and early spica casting (6 months to 6 years old). Older children (> 6 years old) usually benefit from surgical treatments as outcomes of non-surgical alternatives are worse and are associated with prolonged recovery times. These operative measures for older children that are 6-12 years old include elastic stable intramedullary nailing and submuscular plating. Factors to be considered when devising an appropriate intervention include body mass, location of injury, and nature of fracture. For adolescent and skeletally mature teenagers (> 12 years old), rigid antegrade entry intramedullary fixation is indicated. In the event of open fractures or polytrauma, external fixation should be considered as a temporary treatment method for initial fracture stabilization.

CONCLUSION

An age-based and evidence-based algorithm has been proposed to guide surgeons in the process of evaluating an appropriate treatment.

Enhancing stability by penetrating the apophysis of greater trochanter or the posterior neck cortex during titanium elastic nailing of paediatric subtrochanteric femoral fractures in children aged 5-12 years

We modified the traditional titanium elastic nail (TEN) technique to increase stability, by involving the apophysis of the greater trochanter (GT) and the femoral neck cortex. We report the clinical/radiological outcomes after at least 5 years of follow-up. We prospectively included 17 children aged 5-12 years diagnosed with subtrochanteric femoral fractures between January 2004 and December 2013. Radiological evaluations of bony union, malunion, and limb-length discrepancies (LLDs) were performed at the final follow-up. Clinical outcomes, as revealed by the Flynn scoring system, and the range of hip motion were also recorded. The mean patient age was 8.4 ± 2.0 years. Twelve patients presented with length-stable fractures and the others with unstable fractures. Bony union was evident at a mean of 4.5 months postoperatively. Radiologically, malunion >5° was evident in three patients, but all angles were <10° at the final follow-up. LLDs >1 cm were evident in five patients, but all were <2 cm at the final follow-up. Thirteen patients showed excellent outcomes and 4 had satisfactory outcomes. Complications were apparent in only two patients; both showed only temporary discomfort caused by prominent nails. The range of hip motion was satisfactory in all cases; no difference compared to the contralateral hip was apparent. Finally, the radiological/clinical outcomes did not differ by the fracture stability or pattern. We penetrated the apophysis of the GT and the femoral neck cortex with TENs to further stabilise subtrochanteric femoral fractures. This was a simple procedure that enhanced patient outcomes. Level of evidence: therapeutic level II.

Four interventions for pediatric femoral shaft fractures: Network meta-analysis of randomized trials

BACKGROUND

Fractures of the pediatric femoral shaft are uncommon, although serious injuries could lead to long-term disability, pain and an impaired quality of life. There are 4 main interventions: cast (C), plate fixation (PF), titanium elastic nail (TEN) and external fixation (EF). However, for pediatric patients under the age of 16, which intervention is the best choice remains a controversial topic. Therefore, a comprehensive network meta-analysis (NMA) is needed to summarize existing studies and to compare the safety and efficacy of the interventions for pediatric femoral shaft fractures.

METHODS

We searched through eight electronic databases (PubMed, Embase, Cochrane, Web of Science, CBM, CNKI, Wangfang, and VIP) for randomized controlled trials of femoral shaft fracture in pediatric patients, which were published until the end of March 2020. We performed a Bayesian NMA to integrate the adverse events and fracture union time of all interventions.

RESULT

Twenty-three randomized controlled trials with a total number of 1627 patients were included in our NMA. Among these patients, 386 patients underwent C, 524 patients underwent PF, 574 patients underwent TEN, and 143 patients underwent EF. In terms of adverse events, C had the lowest infection rates and TEN the second lowest infection rates. TEN also had the lowest anchylosis and malunion rates. In addition, TEN had a lower fracture union time than C, PF and EF. Notably, C showed the weakest effects on reducing malunion rates in pediatric patients.

CONCLUSION

This current study indicated that TEN has potential superior clinical outcomes in pediatric femoral shaft fractures compared to C, PF and PF. However, high-quality large sample RCTs are still needed.

LEVEL OF EVIDENCE

I.

Titanium Elastic Nailing has Superior Value to Plate Fixation of Midshaft Femur Fractures in Children 5 to 11 Years

BACKGROUND

American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines for pediatric femoral shaft fractures indicate titanium elastic nails (TENs) for children 5 to 11 years old. Growing evidence suggests these fractures may also be treated with open or submuscular plating. The purpose of this study was to compare estimated blood loss (EBL), operative time, fluoroscopy time, cost, and subjective and objective pain scores between TENs and plating techniques used in 5- to 11-year-old children with midshaft femur fractures based on length stability. We hypothesized that EBL, operative time, and fluoroscopy time would be greater and pain would be lower with plate fixation.

METHODS

We retrospectively identified all pediatric midshaft femur fractures treated with TENs, submuscular plating, or open plating between 2004 and 2014. Demographic, injury, and surgical data were obtained for analysis. Cost data were obtained from Synthes Inc. Outcomes were determined using the TEN outcome scoring system. Variables were compared between the 3 fixation methods using paired t tests or Fisher exact test as appropriate. Cost data were compared with Mann-Whitney nonparametric test.

RESULTS

There were 65 midshaft femur fractures in 63 patients included. TENs accounted for 77% and plating 23%. There were no statistical differences in injury severity score, length of stay, length unstable fractures, open fractures, fluoroscopy time, or pain. However, there was a significantly greater operative time (P=0.007) and a notably greater EBL (P=0.057) for the plating technique compared with TENs. Patient outcomes were found to be equivalent. Implant cost was not significantly different although increased surgical costs were seen in plating (P=0.0007).

CONCLUSIONS

This study supports the use of TENs or plating for midshaft femur fractures in children 5 to 11 years old, regardless of length stability. The use of plates resulted in higher EBL, longer operative time, increased cost, and equivalent pain compared with TENs. To our knowledge, this study represents the first direct comparison of the common fixation methods specifically for midshaft femur fractures and favors the use of TENs.

LEVEL OF EVIDENCE

Level III.

Four Weeks in a Single-Leg Weight-Bearing Hip Spica Cast is Sufficient Treatment for Isolated Femoral Shaft Fractures in Children Aged 1 to 3 Years

BACKGROUND

Hip spica casting regimens for the treatment of femoral shaft fractures in a pediatric population aged 1 to 3 years vary. Patient charts were reviewed to determine if there are any clinical differences between 3 and 4 weeks in an ambulatory single-leg hip spica (SLHS) cast versus 6 to 8 weeks in a standard double-leg, non-weight-bearing hip spica cast.

METHODS

The medical records of 109 patients with femoral shaft fractures treated with a hip spica casting from January 1, 2008 to December 31, 2011 were examined. After exclusions, 94 patients were eligible for inclusion in the study. Patient records were assessed, noting age, weight, type of cast, time in cast, and complications. All casts were applied by senior pediatric orthopaedic surgeons at a single institution.

RESULTS

Two groups were evaluated: 59 patients in the SLHS group and 35 in the double-leg hip spica group. The 2 groups were demographically similar with an average age of 2 years, 70.2% of patients were male, 45.7% were black, and 35.1% were white. The average time to cast removal was 4.1 weeks for the single-leg group and 5.3 weeks for the double-leg group (P<0.001). Both groups had similar low rates of loss of reduction. The double-leg group had a significantly higher incidence of clinically significant limb-length discrepancy (7/35, 20%), compared with the single-leg group (1/59, 1.7%, P=0.004). In addition, the double-leg group also had more skin problems (11/35, 31.4%) compared with the single-leg group (6/59, 10.2%, P=0.013). Seventeen patients in the single-leg group were documented as walking in the cast as compared with no patients in the double-leg group (P<0.001).

CONCLUSIONS

Patients treated with a single-leg spica cast for 4 weeks had fewer complications than patients treated in a traditional double-leg cast. Femoral shaft fractures in patients less than 4 years old can be treated in a weight-bearing SLHS casts for approximately 4 weeks with fewer alignment and skin complications.

LEVEL OF EVIDENCE

Level III-clinical retrospective comparative study.