Surgical treatment of femoral fractures in childrenComparison between external fixation and elastic intramedullary nails: A review

Ultrasound-guided techniques for managing length- unstable femoral shaft fractures in children

OBJECTIVE

The management of length-unstable femoral shaft fractures(LUFSFs) in pediatric patients is still controversial. This study aims to explore the clinical efficacy of ultrasound-guided closed reduction combined with external fixation for treating LUFSFs in children.

METHODS

We conducted a retrospective analysis of clinical data from 19 pediatric patients with LUFSFs who underwent ultrasound-guided closed reduction and external fixation between January 2018 and January 2023. Ultrasound was employed not only to facilitate closed reduction of the fracture but also to guide real-time insertion of Schanz pins and monitor pin length as it traversed the opposite cortex. Surgical time, intraoperative fluoroscopy count, hospital stay length, fracture fixation duration, complication incidence, fracture reduction quality at the final follow-up were recorded.

RESULTS

The patients' average age was 7.5 years( range: 5 to 11 years). The mean surgical duration was 70.4 min (range: 48-105 min), and the average intraoperative fluoroscopy count was 6.5 (range: 2-16). Fracture fixation lasted an average of 10.9 weeks (range: 7-20 weeks). All patients were followed up for more than one year. 6 cases of superficial pin tract infection occurred, which resolved with oral antibiotics and enhanced needle tract care. No deep infections were observed. Temporary stiffness of the knee joint was observed in 2 patients. According to Flynn's efficacy evaluation system, fracture reduction quality at the final follow-up was rated as excellent in 11 cases and satisfactory in 8 cases, yielding a combined success rate of 100% (19/19).

CONCLUSIONS

The technique of ultrasound-guided closed reduction combined with external fixation offers favorable outcomes for children aged 5 to 11 years with LUFSFs, reducing reliance on fluoroscopic guidance.

Comparison of antegrade and retrograde cross pin fixation in the surgical treatment of pediatric supracondylar femur fractures: A biomechanical study

PURPOSE

The aim of this study is to compare biomechanical stability of Kirschner wires (K-wires) sent with antegrade and retrograde technique in the fixation of pediatric supracondylar femur fractures.

MATERIALS AND METHODS

A transverse fracture model was created two centimeters above the physis in 24 synthetic bone models suitable for the pediatric femur bone structure. The models were randomly divided into two groups as 12 bones each. In the first group (Group 1), 12 bone fracture models were retrogradely fixed with two cross K-wires. In the second group (Group 2), the fracture was fixed antegradely. In Group 2, both wire ends were allowed to protrude three millimeters from the femoral condyles. The stability of the groups was tested biomechanically by exposing them to varus and extension forces. The forces corresponding to 1 mm, 2 mm, 3 mm and 4 mm displacement and failure loads were calculated in two groups.

RESULTS

According to the test results regarding displacements and failure loads, the retrograde group was found to be significantly stronger than the antegrade group against varus loads (p < 0.05). When the groups were compared in terms of extension strength, the results of the two groups were similar and there was no statistical difference between them (p > 0.05).

CONCLUSION

Retrograde cross K-wires fixation provides a more stable fixation against varus forces. This is important to prevent varus deformity, which is a clinically less tolerable deformity. However, considering that full-weight mobilization of patients is not allowed after surgery in pediatric supracondylar femur fractures, the surgeon should consider that K-wires can also be sent antegrade to decrease the risk of septic arthritis.

Simultaneous bilateral femoral fracture in children

Introduction

Bilateral femoral fractures in children (BFFC) are an uncommon condition. Only a few cases were reported in the literature. The frequency and outcome in low-setting facilities are unknown. This study aims to describe our experience in managing BFFC.

Patients and Methods

A 10-year ongoing study spanning from 2010 to 2020 was held in a level-1 paediatric facility. We included all cases of BFFC on a bone-free disease with at least 10 months of follow-up time. Data were collected and analysed with statistical software.

Results

A total of eight patients with ten BFFC were collected. It involved mainly boys (n = 7/8) with median age of 8 years. Mechanism of injury were a road traffic accident (n = 4), a fall from height (n = 3), and been crushed by a falling wall (n = 1). Associated injuries were frequent (n = 6/8). Patients were managed nonoperatively with spica cast (n = 5) and by elastic intramedullary nails (n = 3). After 6.11 years of mean follow-up time, all fractures healed. The outcome was excellent and good in 7 cases. One patient sustained knees stiffness.

Conclusion

Non-operative management of BFFC showed satisfactory outcomes. Early surgical care must be developed in our low-income settings to reduce in-hospital stay and encourage early weight-bearing.

Closed reduction with crossed Kirschner wire fixation for displaced supracondylar femoral fractures in young children

Supracondylar femoral fractures are uncommon in children, but may result in various deformities. Though many approaches have been used to manage them, there is no literally approved standard yet.From 2015 to 2017, 12 young children at the average age of 2.5 years old (range 3.6-1.6) with displaced supracondylar fractures were admitted to our department and received closed reduction with crossed Kirschner wire (K-wire) fixation as treatment. After the surgeries, we performed follow-up to every patient at the average length of 26 months (range 24-30) and used the Knee Society Score scale to evaluate the outcome.Fracture healing was observed within 10 weeks for all patients and walking was resumed between 10 to 13 weeks. No patient reported a valgus deformity more than 10°, neurovascular injury or knee infection. The average limb length discrepancy was 0.4 cm at the end of our follow-up. Every patient had perfect score on the Knee Society Score scale.Our study suggests that closed reduction with percutaneous crossed Kirschner wire is a favorable method for displaced supracondylar femoral fractures in young children.

Comparison between external fixation and elastic stable intramedullary nailing for the treatment of femoral shaft fractures in children younger than 8 years of age

The main objective of this study was to compare external fixation (EF) with elastic stable intramedullary nailing (ESIN) for the treatment of femoral shaft fractures in children aged 8 or younger. Fifteen children with femoral shaft fractures treated by EF and 23 children with femoral shaft fractures treated by ESIN were retrospectively reviewed. All patients were pain free at the last follow-up, with good ranges of motion in the hip and knee. Partial and full weight bearing occurred sooner in patients treated with EF than with ESIN, although more polytrauma patients were present in the ESIN group. In conclusion, EF and ESIN can be considered as safe and effective methods for femoral shaft fracture treatment in children younger than 8 years of age.

Use of external fixator versus flexible intramedullary nailing in closed pediatric femur fractures: comparing results using data from two cohort studies

PURPOSE

Although external fixation and flexible intramedullary nailing have been extensively used in the management of pediatric femur fractures, there are very few studies, which have compared the results. The purpose of the study was to compare the results of external fixation and flexible intramedullary nailing in pediatric femur fractures.

METHODS

Two groups of patients were treated by external fixator (EF) and flexible intramedullary nailing (FIN) over two different but successive time periods and results compared. The first group (EF) consisted of 45 patients, and the second group had 50 patients.

RESULTS

The age in EF group ranged from 6 to 14 years (average 9.93 years), and the age in FIN group ranged from 6 to 11 years (average 7.66 years). In the EF group, fixator was removed at an average of 12.23 weeks. In the FIN group, radiographic union was evident at an average time of 10.06 weeks. Pin-site infection was common in EF group. One patient had a re-fracture in EF group, and one patient had to be re-operated in FIN group after he developed anterior angulation of more than 30°.

CONCLUSION

We believe that it is the discretion of the surgeon to operate on the femur fracture using either of the treatment modalities. Further randomized studies need to be conducted between these two treatment modalities.

Identification of Differentially Expressed Gene after Femoral Fracture via Microarray Profiling

We aimed to investigate differentially expressed genes (DEGs) in different stages after femoral fracture based on rat models, providing the basis for the treatment of sport-related fractures. Gene expression data GSE3298 was downloaded from Gene Expression Omnibus (GEO), including 16 chips. All femoral fracture samples were classified into earlier fracture stage and later fracture stage. Total 87 DEGs simultaneously occurred in two stages, of which 4 genes showed opposite expression tendency. Out of the 4 genes, Rest and Cst8 were hub nodes in protein-protein interaction (PPI) network. The GO (Gene Ontology) function enrichment analysis verified that nutrition supply related genes were enriched in the earlier stage and neuron growth related genes were enriched in the later stage. Calcium signaling pathway was the most significant pathway in earlier stage; in later stage, DEGs were enriched into 2 neurodevelopment-related pathways. Analysis of Pearson's correlation coefficient showed that a total of 3,300 genes were significantly associated with fracture time, none of which was overlapped with identified DEGs. This study suggested that Rest and Cst8 might act as potential indicators for fracture healing. Calcium signaling pathway and neurodevelopment-related pathways might be deeply involved in bone healing after femoral fracture.

External fixation of pediatric femoral shaft fractures: a consecutive study based on 45 fractures

Forty-five displaced femur fractures in children were treated with unilateral external fixation as a standard treatment from March 2007 to March 2009 and the last follow-up was completed in May 2012. The average age of the children at presentation was 9.93 years. Patients were followed up till union, at 1 year, and at an average of 3.5 years after fixation. The fixator was removed at an average of 12.23 weeks. Twenty-one (47%) patients had a minor complication of pin-site infection. One patient had a major complication of refracture. Treatment of uncomplicated femur fractures using an external fixator in children yields satisfactory results. Our series had a longer duration of follow-up and fewer refractures compared with other series.

The safety of titanium elastic nailing in preschool femur fractures: a retrospective comparative study with spica cast

One hundred and four nonpathological fresh femur fractures not involving the neck or condyles in two groups of preschool children were retrospectively compared and followed up for a minimum of 3 years. Group I was treated by a spica cast and group II was treated by a titanium elastic nail (TEN). The mean age of the children was 4.5 years. TEN was statistically better in terms of union (P=0.000), shortening (P=0.016), sagittal angulation (P=0.018), coronal angulation (P=0.022), rotation (P=0.014), earlier weight bearing (P=0.000), and earlier return to nursery (P=0.000). However, both groups had a similar overgrowth rate and hospital stay time. TEN in preschool children is a safe choice but involves a scar, risk of infection, and the need for a second operation.

Sociodemographic factors influence the risk for femur shaft fractures in children: a Swedish case-control study, 1997-2005

AIM

To investigate how sociodemographic factors relate to the risk of femur shaft fractures in children and how the relationship differs by gender and age.

METHODS

Population-based case-control study. Swedish children (n = 1,874), 0-14 years of age, with a femur shaft fracture diagnostic code occurring between 1997 and 2005 were selected from the Swedish national inpatient register and compared with matched controls (n = 18,740). Demographic, socio-economic and injury data were based on record linkage between six Swedish registers.

RESULTS

The risk of femur shaft fracture increased for children with younger parents or those living in low-income households. Having a parent with a university education reduced the risk. Stratifying for gender and age group, the association between parents' age was evident only for older boys (7-14 years of age) (OR = 1.40; 95% CI 1.04-1.45), and the association between living in low-income households and fracture rate was only seen in older girls (7-14 years) (OR = 1.50; 95% CI 1.01-2.22). Family composition, number of siblings, birth order or receiving social welfare did not influence the fracture risk.

CONCLUSION

Sociodemographic variables influence the rate of femur shaft fractures, in older children the influence differs between boys and girls.

Childhood femoral fracture can lead to premature knee-joint arthritis. 21-year follow-up results: a retrospective study

BACKGROUND AND PURPOSE

During the past decades, treatment of pediatric femoral fractures in Finland has changed from mostly non-operative to more operative. In this retrospective study, we analyzed the long-term results of treatment.

PATIENTS AND METHODS

74 patients (mean age 7 (0-14) years) with a femoral fracture were treated in Aurora City Hospital in Helsinki during the period 1980-89. 52 of 74 patients participated in this clinical study with a mean follow-up of 21 (16-28) years. Fracture location, treatment mode, time of hospitalization, and fracture alignment at union were assessed. Subjective assessment and range of motion of the hip and knee were evaluated. Leg-length discrepancy and alignment of the lower extremities were measured both clinically and radiographically.

RESULTS

Of the 52 children, 28 had sustained a shaft fracture, 13 a proximal fracture, and 11 a distal fracture. 44 children were treated with traction, 5 by internal fixation, and 3 with cast-immobilization. Length of the hospital treatment averaged 58 (3-156) days and the median traction time was 39 (3-77) days. 21 of the 52 patients had angular malalignment of more than 10 degrees at union. 20 patients experienced back pain. Limping was seen in 10 patients and leg-length discrepancy of more than 15 mm was in 8 of the 52 patients. There was a positive correlation between angular deformity and knee-joint arthritis in radiographs at follow-up in 6 of 15 patients who were over 10 years of age at the time of injury.

INTERPRETATION

Angular malalignment after treatment of femoral fracture may lead to premature knee-joint arthritis. Tibial traction is not an acceptable treatment method for femoral fractures in children over 10 years of age.

[Femoral shaft fractures in children]

Femoral shaft fractures in children represent 1.5% of all fractures in childhood. Up to the age of 4 years, conservative treatment in a hip spica or short-term overhead traction is the therapy of choice. Femoral shaft fractures between the age of 5 and 16 years should be treated surgically. In over 90% of these cases elastic stable intramedullary nailing (ESIN) is the premier treatment option. Additional end caps can be used for unstable fractures and in length discrepancy. The external fixator and the locking plate are reserved for fractures with severe soft tissue injuries, vascular problems and some specific situations mentioned later on. By adhering to these standards good results can be achieved with a low complication rate.

Flexible fixation and fracture healing: do locked plating 'internal fixators' resemble external fixators?

External and internal fixators use bone screws that are locked to a plate or bar to prevent periosteal compression and associated impairment of blood supply. Both osteosynthesis techniques rely on secondary bone healing with callus formation with the exception of compression plating of simple, noncomminuted fractures. External fixation uses external bars for stabilization, whereas internal fixation is realized by subcutaneous placement of locking plates. Both of these "biologic" osteosynthesis methods allow a minimally invasive approach and do not compromise fracture hematoma and periosteal blood supply. Despite these similarities, differences between the two fixation methods prevail. Locked plating "internal fixators" allow a combination of biomechanical principles such as buttressing and dynamic compression. Periarticular locking plates are anatomically contoured to facilitate fixation of articular fractures. They allow for subchondral stabilization using small-diameter angular stable screws as well as buttressing of the joint and the metaphyseal component of a fracture. Biomechanically, they can be far stiffer than external fixators, because subcutaneous plates are located much closer to the bone surface than external fixator bars. External fixators have the advantage of being less expensive, highly flexible, and technically less demanding. They remain an integral part of orthopaedic surgery for emergent stabilization, for pediatric fractures, for definitive osteosynthesis in certain indications such as distal radius fractures, and for callus distraction.

Treatment injuries are rare in children's femoral fractures

BACKGROUND AND PURPOSE

The current treatment for femoral fractures in children is mostly operative, which contrasts with treatment of other long bone fractures in children. We analyzed treatment injuries in such patients in Finland in order to identify avoidable injuries. Our other aims were to calculate the incidence of these fractures and to describe the treatment method used.

METHODS

The Patient Insurance Centre (PIC) provides financial compensation of patients who have sustained an injury in connection with medical care. We retrospectively analyzed incidence, treatment methods, and all compensation claims concerning treatment of femoral fractures in children who were 0-16 years of age during the 8-year period 1997-2004.

RESULTS

The incidence of childhood femoral fractures in Finland was 0.27 per 1,000 children aged < 17 years, and two-thirds of the patients were treated operatively during the study period. 30 compensation claims were submitted to PIC during the 8-year study period. The compensation claims mainly concerned pain, insufficient diagnosis or treatment, extra expenses, permanent disability, or inappropriate behavior of medical personnel. Of the claims, 16 of 30 were granted compensation. Compensation was granted for delay in treatment, unnecessary surgery, and for inappropriate surgical technique. The mean amount of compensation was 2,300 euros. Of the injuries that led to compensation, 11 of 16 were regarded as being avoidable in retrospect.

INTERPRETATION

The calculated risk of a treatment injury in childhood femoral fracture treatment in Finland is approximately 2%, and most of these injuries can be avoided with proper treatment.

Treatment of femoral fractures in children: is titanium elastic nailing an improvement over hip spica casting?

PURPOSE

The purpose of the study was to assess the validity of surgical interference with elastic nailing in treating pediatric femur fractures in comparison with the traditional treatment method-hip spica casting.

METHODS

Sixteen consecutive femur fractures in children 5-15 years of age were recruited prospectively over 13 months. An equal number of age-matched children treated by spica casting were recruited retrospectively. Subtrochanteric, supracondylar femur fractures were excluded.

RESULTS

Fracture union occurred earlier in the surgical group (6 weeks) than in the spica group (8 weeks) (P = 0.001). Spica casting caused higher coronal plane angulation (P = 0.001), higher rotational malalignment (P < 0.001), higher limb length discrepancy at 1-year follow-up (P < 0.001), longer duration of immobilization (P < 0.001), later full weight-bearing (P < 0.001), and greater absence from school (P < 0.001). Flynn outcome scores were better with titanium elastic nailing than with hip spica casting.

CONCLUSION

Titanium elastic nailing led to better outcomes compared to hip spica casting in terms of earlier union, lower rates of malunion, shorter rehabilitation milestones, and better functional outcome scores.