Current trends in the treatment of femoral shaft fractures in children and adolescents

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.

Regionalization of Isolated Pediatric Femur Fracture Treatment: Recent Trends Observed Using the Kids' Inpatient Database

BACKGROUND

Isolated pediatric femur fractures have historically been treated at local hospitals. Pediatric referral patterns have changed in recent years, diverting patients to high volume centers. The purpose of this investigation was to assess the treatment location of isolated pediatric femur fractures and concomitant trends in length of stay and cost of treatment.

METHODS

A cross-sectional analysis of surgical admissions for femoral shaft fracture was performed using the 2000 to 2012 Kids' Inpatient Database. The primary outcome was hospital location and teaching status. Secondary outcomes included the length of stay and mean hospital charges. Polytrauma patients were excluded. Data were weighted within each study year to produce national estimates.

RESULTS

A total of 35,205 pediatric femoral fracture cases met the inclusion criteria. There was a significant shift in the treatment location over time. In 2000, 60.1% of fractures were treated at urban, teaching hospitals increasing to 81.8% in 2012 (P<0.001). Mean length of stay for all hospitals decreased from 2.59 to 1.91 days (P<0.001). Inflation-adjusted total charges increased during the study from $9499 in 2000 to $25,499 in 2012 per episode of treatment (P<0.001). Total charges per hospitalization were ∼$8000 greater at urban, teaching hospitals in 2012.

CONCLUSIONS

Treatment of isolated pediatric femoral fractures is regionalizing to urban, teaching hospitals. Length of stay has decreased across all institutions. However, the cost of treatment is significantly greater at urban institutions relative to rural hospitals. This trend does not consider patient outcomes but the observed pattern appears to have financial implications.

LEVEL OF EVIDENCE

Level III-case series, database study.

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.

Treatment of Closed Femoral Shaft Fractures in Children Aged 6 to 10

BACKGROUND

Management of pediatric femoral shaft fractures remains controversial, particularly in children between the ages of 6 and 10. In the current push toward cost containment, hospital type, and surgeon subspecialization have emerged as important factors influencing this treatment decision. Thus, in the present study, we use a nationwide pediatric inpatient database to compare the: (a) incidence; (b) demographic characteristics; (c) hospital costs; (d) length of stay; and (e) treatment method of pediatric closed femoral shaft fractures admitted to general versus children's hospitals.

METHODS

The Kids' Inpatient Database (KID) was queried for all patients aged 6 to 10 who sustained a closed femoral shaft fracture in 2009 or 2012, and patient records were stratified into children's hospitals and general hospitals. Primary outcome measures included method of treatment, total hospital costs, and length of stay. Student/Welch t testing and χ analysis were utilized to compare continuous and categorical outcomes, respectively, between hospital types.

RESULTS

The total incidence of closed femoral shaft fractures decreased between 2009 and 2012 (1919 to 1581 patients; P=0.020), as did the proportion of patients treated in children's hospitals (58.6% to 32.3%; P<0.001). In addition, patients treated at general hospitals were more likely to receive open reduction with internal fixation (45.3% vs. 41.1%) or external fixation (4.1% vs. 2.3%), and less likely to be managed with closed reduction with internal fixation (32.0% vs. 39.7%) than those treated at children's hospitals (P<0.001 for all).

CONCLUSIONS

The present study demonstrates a decrease in the incidence of closed femoral shaft fractures in 6- to 10-year old patients from 2009 to 2012, as well as decreased definitive management in children's hospitals and increased selection of operative treatment. In addition, treatment in a nonchildren's hospital was associated with decreased total inpatient costs and decreased treatment with closed reduction with internal fixation in favor of open reduction with internal fixation. Future studies should seek to identify the specific surgical procedures performed and match patients more closely based specific fracture pattern.

LEVEL OF EVIDENCE

Prognostic level II.

Titanium elastic nailing in pediatric femoral diaphyseal fractures in the age group of 6-15 years mid-term and long-term outcomes

Objective:

To evaluate the effectiveness of Titanium Elastic Nailing (TEN) used in the surgical treatment of pediatric femoral shaft fractures and the effect of the complications to the outcome. Another objective was to assess the changing of Limb Length Discrepancy (LLD) and angulation degree with prolonged follow-up time and to evaluate whether the patient had a functional problem because of this situation.

Methods:

Thirty children between the ages of 6 and 15 who had femur shaft fractures were evaluated. The times of operation, ambulation, bone union and follow-up were recorded. Post-operative complications were evaluated between 1996-2016 with at least 24 Months follow up.

Results:

The mean follow-up was 52.5 ± 49.0 months (range 24-240). The mean varus angulation was 3.2 ± 5.1 degrees. The length of the fracture side was approximately 0.71 ± 0.58 cm (range 0-2.09 cm) longer than the intact side. There were eight patients with LLD of 1-2 cm. There was no statistically significant relationship between the type, location, and age of fracture of the LLD (P> 0.05). It was evaluated according to Flynn’s criteria. According to this, 12 (40%) of the patients’ results were excellent, 14 (46.7%) were good, and four were poor.

Conclusion:

TEN is an effective, easy, fast treatment method and has minimal complications for the treatment of femoral shaft fractures in childhood. Most complications can be reduced by performing basic principles and technical directions. Although LLD is a common complication of childhood femur fractures, the disease does not present a functional problem in daily life.

Changes in the Treatment of Pediatric Femoral Fractures: 15-Year Trends From United States Kids' Inpatient Database (KID) 1997 to 2012

BACKGROUND

The options for treating femoral fractures in children and adolescents have evolved over the last 2 decades to include a variety of nonoperative and operative methods. The purpose of this study was to identify changes in the types of treatment for pediatric femoral fractures in the United States from 1997 to 2012.

METHODS

From discharge estimates for 1997, 2000, 2003, 2006, 2009, and 2012 in the Kids' Inpatient Database, data were extracted using the International Classification of Diseases, 9th revision, and Clinical Modification for pediatric femoral fracture treatments. Patients included were 0 to 17 years old and were categorized into 5 age groups: younger than 1, 1 to 4, 5 to 9, 10 to 14, and 15 to 17 years.

RESULTS

A total of 74,483 estimated discharges were recorded for pediatric patients with femoral fractures in the database for years 1997, 2000, 2003, 2006, 2009, and 2012. A total of 12,986 pediatric femoral fractures were estimated for 1997 and 9813 for 2012, which was statistically different (P<0.0001). Significantly fewer fractures were treated with closed reduction alone in 2012 than in 1997 in age groups 5 to 9, 10 to 14, and 15 to 17 years. Children aged 5 to 9 had more frequent open reduction and internal fixation in 2012 than in 1997, whereas adolescents aged 15 to 17 had less frequent open reduction and internal fixation in 2012 than in 1997.

CONCLUSIONS

Although the number of femoral shaft fractures overall has decreased, the frequency of operative treatment has increased significantly in patients 5 to 9 years of age. Knowledge of these trends can guide educational efforts and resource allocation, but further study is necessary to determine procedure-specific (eg, nailing, plating, external fixation) trends and their clinical and economic impacts.

LEVEL OF EVIDENCE

Level III-case series.

Titanium elastic nailing in diaphyseal femoral fractures of children below six years of age

AIM

To report the clinical and radiographic results of titanium elastic nail (TEN) in diaphyseal femoral fractures of children below age of six years.

METHODS

A retrospective analysis of 27 diaphyseal femoral fractures in children younger than six years treated with TEN between 2005 and 2015 was conducted. Patients were immobilized in a cast for 5 wk and the nails were removed from 6 to 12 wk after surgery. Twenty-four cases were clinically and radiographically re-evaluated using the Flynn’s scoring criteria, focusing on: Limb length discrepancy, rotational deformity, angulation, hip and knee range of motion (ROM), functional status, complications, and parent’s satisfaction.

RESULTS

Sixteen males and eight females with a mean age of 3.2 years at the time of treatment were re-evaluated at an average follow-up of 58.9 mo. No cases of delayed union were observed. The mean limb lengthening was 0.3 cm. Four cases experienced limb lengthening greater than 1 cm and always minor than 2 cm. Twelve point five percent of the cases showed an angulation < 10°. Complete functional recovery (hip and knee ROM, ability to run and jump on the operated limb) occurred in 95.7% of cases. Complications included two cases of superficial infection of the TEN entry point, one case of refracture following a new trauma, and one TEN mobilization. According to the Flynn’s scoring criteria, excellent results were obtained in 79.2% of patients and satisfactory results in the remaining 20.8%, with an average parent’s satisfaction level of 9.1/10.

CONCLUSION

TEN is as a safe, mini-invasive and surgeon-friendly technique and, considering specific inclusion criteria, it represents a useful and efficacy option for the treatment of diaphyseal femoral fractures even in patients younger than six years of age.

Pediatric femoral shaft fractures: treatment strategies according to age--13 years of experience in one medical center

Objective

The objective of this study was to analyze our experience in treating femoral shaft fractures with different strategies, focusing on the first year after injury when the choice of method would have the greatest impact.

Methods

We reviewed the medical records of all children treated for femoral shaft fractures in our institution between 1997 and 2010. They were divided according to therapeutic approach: spica cast, skin traction, titanium elastic nail (TEN), external fixator, intramedullary medullary nail (IMN), and plating.

Results

The 212 patients included 150 boys and 62 girls (M/F ratio 2.4:1, mean age 5 years, range 0–16). The postoperative radiographic results demonstrated solid union in all patients, with no malunions. Of the 151 children in the spica cast group, 10 required re-manipulation and casting due to loss of reduction with unaccepted angulation, 10 had contact dermatitis, and 2 had fever and pressure sores. All 21 elastic nail group children underwent re-operation to remove the hardware: 3 had soft tissue irritation at the insertion points, and 3 had leg length discrepancy (LLD). Of the 14 external fixation patients, 4 had LLD, 1 had a pin tract infection, and 1 had a fracture through a pinhole after a fall. There were no complications in the 12 IMN patients, the 3 plating patients, or the 11 skin traction patients. LLD rates in the spica group were 10.5% higher compared to those in the control group (other treatment modalities) (P = .03).

Conclusions

TEN treatment was superior to spica casting for children who had reached an average age of 4 years.

Management of pediatric diaphyseal femur fractures

A variety of strategies are utilized for management of pediatric diaphyseal femur fractures, depending chiefly on the age of the patient. Other factors that can influence the selection of a technique-which range from skeletal traction with spica casting to immediate spica casting, flexible intramedullary nailing, rigid intramedullary rodding, or plate fixation-are weight, fracture severity, associated injuries, and underlying medical or musculoskeletal conditions. The available evidence regarding technique, outcomes, and complications of the aforementioned treatment options remains largely insufficient, and, at times, conflicting, which contributes to the challenges in management decisions. Considerable controversy has arisen over several topics, particularly the optimal treatment for patients aged 5 to 12 years and accepted standards of treatment. This review is designed to provide perspective for some of the most recent influential literature on pediatric diaphyseal femur fracture treatment in light of established evidence and evolving controversies.

A comparison of locked versus nonlocked Enders rods for length unstable pediatric femoral shaft fractures

BACKGROUND

Stainless steel flexible Enders rods have been used for intramedullary fixation of pediatric femur fractures with good success. Despite intraoperative anatomic alignment, length unstable femur fractures can present postoperatively with fracture shortening. The purpose of this study was to review all length unstable pediatric femoral shaft fractures in which Enders rods were used and compare those that were locked to those that were not locked.

METHODS

A retrospective clinical and radiographic review of all patients at a single institution undergoing flexible intramedullary fixation for length unstable femoral shaft fractures from 2001 to 2008. A length unstable fracture was defined as either a comminuted fracture or a spiral fracture longer than twice the diameter of the femoral shaft. A total of 107 length unstable femoral shaft fractures fixed with Enders rods were identified, of which 37 cases (35%) had both Enders rods "locked" through the eyelet in the distal femur with a 2.7 mm fully threaded cortical screw. Patient demographics, clinical course, complications, fracture characteristics, and radiographic outcomes were compared for the locked and nonlocked groups.

RESULTS

There were no statistical differences between the groups in demographic data, operative variables, fracture pattern, fracture location, time to union, femoral alignment, or major complications. Shortening of the femur and nail migration measured at 1 to 6 weeks postoperatively was significantly greater for the nonlocked cases. The medial and lateral locked Enders rods moved 1.3 and 1.9 mm, respectively, and the unlocked Enders each moved 12.1 mm (P < 0.05). At final follow-up there were significantly more (P < 0.05) clinical complaints in nonlocked group, including limp, clinical shortening, and painful palpable rods.

CONCLUSIONS

Locking Enders rods for length unstable pediatric fractures is an excellent option to prevent shortening and resulted in no additional complications, added surgical time, or increased blood loss.

LEVEL OF EVIDENCE

Level III.

Biomechanical analysis of a synthetic femoral spiral fracture model: Do end caps improve retrograde flexible intramedullary nail fixation?

Background

Elastic Stable intramedullary Nailing (ESIN) of dislocated diaphyseal femur fractures has become an accepted method for the treatment in children and adolescents with open physis. Studies focused on complications of this technique showed problems regarding stability, usually in complex fracture types such as spiral fractures and in older children weighing > 40 kg. Biomechanical in vitro testing was performed to evaluate the stability of simulated spiral femoral fractures after retrograde flexible titanium intramedullary nail fixation with and without End caps.

Methods

Eight synthetic adolescent-size femoral bone models (Sawbones^® with a medullar canal of 10 mm and a spiral fracture of 100 mm length identically sawn by the manufacturer) were used for each group. Both groups underwent retrograde fixation with two 3.5 mm Titanium C-shaped nails inserted from medial and lateral entry portals. In the End Cap group the ends of the nails of the eight specimens were covered with End Caps (Synthes Company, Oberdorf, Switzerland) at the distal entry.

Results

Beside posterior-anterior stress (4.11 Nm/mm vs. 1.78 Nm/mm, p < 0.001), the use of End Caps demonstrated no higher stability in 4-point bending compared to the group without End Caps (anterior-posterior bending 0.27 Nm/mm vs. 0.77 Nm/mm, p < 0.001; medial-lateral bending 0.8 Nm/mm vs. 1.10 Nm/mm, p < 0.01; lateral-medial bending 0.53 Nm/mm vs. 0.86 Nm/mm, p < 0.001) as well as during internal rotation (0.11 Nm/° vs. 0.14 Nm/°, p < 0.05). During compression in 9°- position and external rotation there was no statistical significant difference (0.37 Nm/° vs. 0.32 Nm/°, p = 0.13 and 1.29 mm vs. 2.18 mm, p = 0.20, respectively) compared to the "classic" 2-C-shaped osteosynthesis without End Caps.

Conclusion

In this biomechanical study the use of End Caps did not improve the stability of the intramedullary flexible nail osteosynthesis.

Biomechanical analysis of a synthetic femur spiral fracture model: Influence of different materials on the stiffness in flexible intramedullary nailing

BACKGROUND

Flexible intramedullary nail fixation of dislocated diaphyseal femur fractures has gained wide acceptance for children and adolescents with open physes. Studies with a special emphasis on complications reveal frequent problems regarding stability, usually in complex fracture types such as spiral fractures and in older children weighing >40kg. This biomechanical study analyses how much the material of the nails influences the stiffness in a synthetic bone model.

METHODS

Twenty-four composite grafts (Sawbones®, 4th generation, medullar canal of 10mm) with an identical spiral fracture were used in three configurations of eight grafts. Elastic stable intramedullary nailing was performed in a retrograde C-shaped manner with two nails of equal size (2×3.5mm). Close contact of the fragments could be achieved. We compared Group A (steel nails) with Group B and C (two types of titanium nails). All specimens underwent 4-point bending, torsion and axial compression in the 0° and 9° positions, and the results were analysed.

FINDINGS

Group A (steel nails) revealed a significantly higher stiffness in all directions than Group B. Apart from compression in the 9° position this steel nail fixation showed significant higher stiffness than titanium nails of Group C. Comparing Group B and C did not show an systematic difference.

INTERPRETATION

In this biomechanical study with composite artificial bones the use of steel Nails demonstrated the highest stiffness in our model when compared to two different titanium nail configurations. Apart from in cases of known allergy or planned MRI-examinations our results and data from the literature question the use of titanium nails.

[Pediatric femur fractures, epidemiology and treatment]

BACKGROUND/AIM

Femur fractures in children most often occur as a consequence of traffic accidents, during play and sport activities, and due to different pathological states. Diagnosis is rather simple and it includes physical and radiographical examination. Femur fractures treatment in children can be operative and unoperative, depending on several facts: age, localisation and type of fracture, joint injuries of soft tissues, the presence of other injuries (in polytrauma), economical and social aspects, ect. The aim of this study was to present epidemiological characteristics of pediatric femur fractures, that is in the stage of development, including a special analysis of the used treatment techniques, as well as the comparison of the obtained data with those from the literature.

METHODS

The evaluation included following parameters: age, gender, cause, localisation and type of femur fracture, applied treatment and hospitalisation duration.

RESULTS

Among the presented 143 patients with femur fracture, 109 were boys and 34 were girls (3.2:1 ratio; p = 0.0001). Average age for both genders was 8.6 years, and no difference between boys and girls were found for the age (p = 0.758). In total, the most common fracture was diaphyseal fracture of femur in 93 (65.03%) patients. The second was proximal fracture in 30 (20.98%) patients, and the last distal fracture of the femur in 20 (13.99%) patients (p = 0.0001). Three main causes of femur fracture can be distinguished: during play and sport activities in 67 (46.8%) children, in traffic accidents in 64 (44.8%) children, and pathological fractures in 12 (8.4%) children. Inoperative treatment was applied in 82 (57.3%) patients, and operative one in 61 (42.7%) patients. The most common treatment was traction, in 71 (49.6%) patients, followed by immobilization by hip spica cast mostly in young children. Intramedullar elastic nailing was applied in 16 (11.2%) cases, and intra-medullar rigid nailing (Küntscher) in 19 (13.3%) cases. Significantly longer hospitalization period was detected after traction (21 days) comparing to other ways of treatment, mainly operative or hip spica cast (5 to 10 days).

CONCLUSION

In young children the standard treatment was hip spica cast after traction. Intramedullar elastic nailing is a modern trend accepted as standard in our approach to femur fracture treatment in children.

Residual deformity after treatment of pediatric femur fractures with flexible titanium nails

INTRODUCTION

Procurvatum or anterior bow deformity is a potential complication after treatment of femur fractures with flexible titanium nails (FTNs). This article reports on a clinical evaluation of angulation after treating pediatric femur fractures with FTNs. The article also reports on a complementary investigation of potential causes of these deformities using a biomechanical model.

METHODS

All pediatric femoral shaft fractures treated with FTNs over a 4-year period were reviewed. Fracture location, pattern, angulation, and nail shoe tip orientation were recorded from postoperative radiographs. Malunion was defined as greater than 10 degrees of angulation on the AP radiograph or greater than 15 degrees on the lateral view. As an adjunct to the clinical study, a synthetic femur model was created using midtransverse fractures. These femurs were nailed using 2 FTNs inserted so as to create constructs having the following combinations of nail shoe tip orientation: both anterior (AA), both posterior (PP), both neutral (NN), or 1 anterior and 1 posterior(AP). The resulting angular deformities noticeable upon gross inspection were then measured.

RESULTS

Of the 70 fractures reviewed, malunion occurred in 16 fractures, of which 11 had increased anterior bow. A majority of malunions was observed in older children with middle third of the femur fractures. They were significantly more prevalent in transverse fractures compared with all other fracture patterns. Clinically, increased anterior bowing did not occur if 1 of the nails was positioned to resist procurvatum, as seen in the lateral radiograph. Depending on nail tip orientation, the biomechanical femur fracture model showed significant differences in mean deformations after nail placement: AA had 12.6 degrees of posterior bow compared with 14.8, 3.7, and 0.3 degrees of anterior bow for PP, NN, and AP, respectively.

CONCLUSION

Anterior bowing greater than 15 degrees is the most common malunion noted in this series of femur fractures that were nailed using FTN's. We conclude that final nail shoe tip orientation influences the likelihood of anterior bow deformity. The likelihood of large anterior bowing may be reduced if at least 1 of the nails is inserted with the tip pointing in an anterior direction. LEVEL OF EVIDENCE/CLINICAL RELEVANCE: Level III.

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.

Femoral nailing to treat fractures after lengthening for congenital femoral deficiency in young children

Congenital femoral deficiency in children can be treated with femoral lengthening. A common complication is fracture soon after removal of the external fixator, often despite prophylactic hip spica cast application. These fractures present special challenges because the patients have tight soft tissues and sclerotic intramedullary canals. We treated nine such fractures in eight children (average age, 5.4 years). Most were 'spontaneous' events resulting in transverse fracture through regenerate bone or pin sites. All were stabilized with intramedullary Rush pins using special insertion techniques. Union was achieved (average, 6 weeks); no significant complications occurred. We describe details of the surgical technique.

Immediate incorporated hip spica casting in pediatric femoral fractures: comparison of efficacy between normal and high-risk groups

BACKGROUND

Immediate hip spica casting is the most commonly used method for the treatment of pediatric femoral fractures. The main disadvantage of the method is the unacceptable shortening (>25 mm), which may occur during the treatment. Buehler et al described the so-called telescope test to identify the cases with a relatively high risk of unacceptable shortening. On the basis of this test, patients with an overriding of the fracture ends of more than 30 mm have a 20.4 times higher risk of unacceptable shortening compared with those with an overriding of less than 30 mm. This relatively higher risk of unacceptable shortening may be avoided by a hip spica cast, which is incorporated to a distal femoral traction pin.

METHODS

The study consists of 47 (26 boys and 21 girls) patients. Mean age was 40.3 months (range, 18 months to 6 years). Patients were divided into 2 groups according to the telescope test. Group 1 included patients with telescope test results of more than 30 mm. Group 2 included patients with telescope test results of 30 mm or less. All patients were treated with a hip spica cast, which is incorporated to a distal femoral traction pin within 8 hours of the initial trauma. During cast treatment, patients were followed up by weekly x-ray controls for the first month. Patients were assessed for unacceptable shortening and misalignment.

RESULTS

Mean (SD) shortening during cast treatment was 2.9 (5.1) mm on the treated site. Shortening was detected in 16 patients (88.9%) in group 1 and in 7 patients (24.1%) in group 2. A significantly higher number (P < 0.001) of patients developed shortening in group 1. However, unacceptable shortening (>25 mm) did not develop in any patient in both groups. There was no significant frontal plane malalignment in both groups (P > 0.05). Sagittal plane malalignment was significantly higher in group 1 (P < 0.05).

CONCLUSIONS

Hip spica cast, which is incorporated to a distal femoral traction pin, avoids unacceptable shortening and frontal plane malalignment in pediatric femoral fractures, which even have a relatively high risk of unacceptable shortening based on the so-called telescope test. However, the technique cannot avoid sagittal malalignment.

Flexible interlocked nailing of pediatric femoral fractures: experience with a new flexible interlocking intramedullary nail compared with other fixation procedures

BACKGROUND

The optimal treatment of femoral shaft fractures in older children and adolescents remains controversial. We hypothesized that fixation with a flexible interlocking intramedullary nail (FIIN) reduces perioperative complications and improves outcomes, including leg-length discrepancy, time to healing, and time to weight bearing compared with other fixation procedures (OFPs) including standard elastic nail implants.

METHODS

Using a retrospective cohort study design, we reviewed medical records and radiographs of children, 7 to 18 years of age, with femoral shaft fractures requiring open treatment between July 1, 1998, and June 30, 2003. Patients selected for the study had unilateral fracture sites proximal to the supracondylar region and distal to the lesser trochanter, presence of open femoral growth plates, and open surgical treatment. Analyses compared inpatient measures and patient outcomes between FIIN and OFP groups.

RESULTS

Of the 160 patients eligible for inclusion, 23 were lost to follow-up. The remaining 137 patients had a mean follow-up of 396.3 days (SD, 320.4 days), with 58 receiving FIIN fixation and 79 OFP. Although the difference was not statistically significant, complications occurred in 19.0% of patients in the FIIN group and 30.4% in the OFP group. Trochanteric heterotopic ossification was the most common complication (13.8%) noted in the FIIN group and superficial infection (12.8%) in the OFP group. The FIIN group experienced less blood loss (P = 0.042) and shorter time to weight bearing (P = 0.001) without disturbance of proximal femoral geometry or avascular necrosis of the femoral head. In children weighing less than 45.5 kg (100 lb), complications were less common with FIIN (3.6%) compared with OFP (24.4%). A subgroup of patients less than 45.5 kg (100 lb) with standard elastic nail implants (n = 24) had 8.1 times the complications of patients with FIIN.

CONCLUSIONS

Older children and adolescents with femoral shaft fractures treated with a FIIN showed improved outcomes compared with patients treated with OFP.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Dynamic skeletal traction spica casts for paediatric femoral fractures in a resource-limited setting

The objective of this study was to compare elastic intramedullary nailing (EIN) with dynamic skeletal traction spica casting (DSTSC) in terms of postoperative radiographic angulations, length of hospital stay, and cost in a resource-limited setting. We prospectively studied 51 children, five to twelve years of age, with femoral fractures treated with either EIN (n = 26) or DSTSC (n = 25). Children treated with EIN had significantly longer hospital stays (17 +/- 8.0 days) than those treated with DSTSC (6.0 +/- 2.5 days). Financial constraints in acquiring supplies caused a significant increase in time from admission to surgery (EIN 9.5 +/- 2.3 days; DSTSC 1.1 +/- 0.3 days), and cost was about 400% higher for EIN compared with DSTSC. At twelve weeks follow-up, all patients in both groups had acceptable radiographic angulations. In resource-limited healthcare settings, DSTSC is an effective alternative to EIN with comparable post-op radiographic angulations, decreased hospital stays, and lower cost.

Femoral fractures in children, is early interventional treatment beneficial?

A protocol of early intervention (flexible intramedullary nails, early hip spica, and external fixation) was started in 1999 and during a 3-year period there were 25 children who sustained a femoral shaft fracture (early intervention group). These were prospectively reviewed with a minimum follow up of 24 months (Range 24-35 months). A historical control group of 41 children was used. These children were injured between February 1996 and February 1999 and were retrospectively reviewed. They had traditional in patient treatments with either Gallows or Thomas splint traction (traditional treatment group). Over the 6-year period from 1996 to 2002 there were a total of 66 femoral shaft fractures in the study that presented to our hospital. The mean length of hospital stay was 29 nights in the traditional group and 10 nights in the early intervention group. This difference is significant (p<0.001). The malunion rate was slightly higher in the early active group at radiological union but most of these remodelled over the 2 years of follow up. The protocol of early intervention used in our institution, of flexible nails, early hip spica or external fixation depended on the age of the child, and has resulted in a shorter hospital stay for the children. This has benefits for the child, the family and the hospital.

Paediatric femoral fractures: factors influencing length of stay and readmission rate

AIM

This report describes factors influencing length of stay and unplanned readmissions within 30 days of discharge for children presenting with femoral fractures to Starship Hospital.

METHODS

The charts and radiographs of all children admitted with femoral shaft fractures between January 1998 and December 2002 were reviewed, excluding pathological fractures. The type of management, the length of stay and the unexpected readmission rate within 30 days were recorded. Ninety-three children with 95 femoral fractures were included in the study.

RESULTS

Forty-six fractures were treated by application of immediate hip spica and 49 by other surgical methods (21 by external fixation, 20 by flexible intramedullary nailing and 8 by other methods). Patients with isolated femur fractures treated by either hip spica application or other operative fixation had median lengths of stay of 3 days (range 1-10 days) and 6 days (range 2-15 days), respectively. Patients with associated injuries, whose femur fractures were treated by either hip spica application or other operative fixation, had longer median lengths of stay of 5 days (3-15 days) and 17 days (5-70 days), respectively. Nine of the 93 children had an unplanned return to the operating theatre during their initial hospital stay, with increased length of stay in 5 as a result. A further 21 children were readmitted within 30 days of discharge with problems of loss of fracture alignment and cast damage in the hip spica group; pin-site infections in the external fixation group and pain around the distal nail insertion site in the flexible intramedullary nailing group. Despite these early problems, fracture alignment was satisfactory at union in 89 of the 95 fractures, with satisfactory remodelling in the remaining six fractures at follow-up.

CONCLUSIONS

The presence of associated injuries was a key factor in the length of the initial hospital stay. However, the need for further operative interventions in the first hospital stay also increased the length of stay in some patients. Overall, the operative management of femoral fractures is resource intensive with a significant need for further minor operative intervention, regardless of the type of initial management.

Skin traction in hip spica casting for femoral fractures in children

BACKGROUND

The purpose of this study was to evaluate the skin traction in hip spica casting when applied as the standard treatment for children with femoral shaft fractures.

METHODS

A total of 207 patients with femoral fractures were treated with this method. The average age was 4.7 years. After the application of skin traction, the fracture of the femur was reduced and was placed in a hip spica cast. Traction was continued in the cast.

RESULTS

All fractures united within 4-8 weeks. No significant residual angular deformities were seen in any of the children. The only complication was refracture in two children who fell after removal of the cast. None of the children required external shoe lifts, epiphysiodesis, antibiotics, irrigation, or débridement.

CONCLUSIONS

Skin traction and a well-molded hip spica cast is a safe, reliable treatment option for isolated, closed femoral fractures in children 2-7 years of age.

Traction and spica casting for closed femoral shaft fractures in children

PURPOSE

To evaluate the treatment outcome of skin traction followed by spica casting for closed femoral shaft fractures in children.

METHODS

Between September 1997 and December 2001 inclusive, outcomes of 63 children aged one month to 15 (mean, 5.3) years with closed femoral shaft fractures managed with skin traction and spica casting were reviewed. Depending on age, patients were kept in traction from 2 to 15 (median, 9) days, then in spica casts for 2 to 8 (median, 5) weeks.

RESULTS

Bony union took 3 to 12 (median, 6) weeks. There were no malunion, nonunion, or rotational deformities. Nor were there any significant limb length discrepancies, pressure sores, or nerve palsies. On no occasion was a spica cast removed and reapplied for loss of fracture reduction. At final follow-up, limb length discrepancy was noted in 14 (22%) of the patients, but none had a discrepancy of greater than 1.5 cm or a short-legged gait.

CONCLUSION

Skin traction followed by spica casting for closed femoral shaft fractures in children is safe, cost-effective and associated with a low complication rate. It is effective in children below 5 years of age and no less effective in older children, except in instances of open fracture, multiple fractures, or older children with large statures, which conditions render them intolerant to spica casts.

Titanium elastic nailing in femoral diaphyseal fractures of children in 6-16 years of age

BACKGROUND

Management of femoral diaphyseal fractures in the age group of 6-16 years is controversial. There has been a resurgence worldwide for operative fixation.

MATERIALS AND METHODS

Twenty-two children (18 boys, 4 girls) aged 6-16 years with recent (> 3 days) femoral diaphyseal fractures (20 closed, 2 open) were stabilized with Titanium Elastic Nail (TEN). These fractures were in proximal third (n=3), middle third (n=15) and in the distal third (n=4) 17 patients underwent surgery within seven days of their injury. The results were evaluated using Flynn's scoring criteria. Statistical analysis was done using Fischer's exact test.

RESULTS

All 22 patients were available for evaluation after a mean of 26 months (14-36 months) of followup. Radiological union in all cases were achieved in a mean time of 8.7 weeks. Full weight bearing was possible in a mean time of 8.8 weeks. Mean duration of hospital stay was 9.8 days. The results were excellent in 13 patients (59.0%), successful in six (27.2%) and poor in three patients (13.6%). All patients had early return to school.

CONCLUSION

Intramedullary fixation titanium elastic nailing is an effective treatment of diaphyseal fractures of the femur in properly selected patients of the 6-16 years age group.

Immediate single-leg spica cast for pediatric femoral diaphysis fractures

PURPOSE

Immediate spica cast application is the standard of care for young children with isolated femur fractures. We evaluated the outcomes and function of children treated with single-leg spica casts.

METHODS

We performed a retrospective review of 45 children treated with single-leg spica casts. Demographic data, mechanism of injury, hospitalization time, time in cast, and complications were collected by chart review. Children returned for a physical examination and radiographs. Subjects completed a questionnaire about the child's functional level and the Activities Scale for Kids.

RESULTS

There were 33 boys and 12 girls. The average age was 3.3 (9 months to 9 years). The mechanism of injury was a fall in 71%. The mean hospitalization was 1 day (0-4 days) and the mean time to union was 6 weeks (4-9 weeks). Ninety-five percent of the patients crawled in the cast, 90% pulled to stand, 81% cruised, and 62% walked either independently or with assistive devices. One half of the patients in school or daycare returned while in the cast. Two children failed because of unacceptable shortening. Two children required repeat reductions under anesthesia due to unacceptable alignment. Five casts broke at the hip joint. At final review, there was 1 rotational malunion. There were no radiographic malunions. The median Activities Scale for Kids score was 95 of 100 possible points.

CONCLUSIONS

The single-leg spica can safely, effectively manage low-energy femur fractures in young children.

SIGNIFICANCE

The single-leg spica may address some of the social concerns associated with the use of a spica cast for simple femur fractures.

Impact of External Fixation on Adolescents

PURPOSE

To define the state of nursing knowledge about the psychological impact of treating adolescents with external fixation devices (EFDs).

METHOD

An integrated research review was conducted on literature available from CINAHL, MEDLINE, and PsycINFO. Keywords used were external fixation, fracture fixation, orthopaedic or orthopaedic, limb lengthening, Ilizarov, halo traction, Orthofix, EBI fixator, pelvic fixator, ring fixator, body image, self-concept, self-esteem, self-perception, adaptation, emotional, behavior, and outcome. Inclusion criteria for studies were (a) publication from 1990 to 2003, (b) focus on psychosocial and functional outcomes of treating adolescents with EFDs, and (c) publication in English. Studies were categorized by author, year, discipline(s), design, focus, sample, measurement, findings, and research recommendations. Findings and recommendations were compared across publications.

RESULTS

All studies reported psychological and behavioral changes after EFD treatment. Pain and pin-site infections were the most problematic physical findings. Depression was universally evident to varying degrees, with some suicidal ideation and self-destructive behaviors, although mostly reported as transient. This predominantly retrospective cohort of studies reported social isolation as well as eating and sleep disturbances. Family and nursing support, a multiple disciplinary approach, and better preoperative preparation were crucial to adolescents psychological health after EFD treatment.

CONCLUSION

Adolescents treated with EFDs require significant psychosocial support. The findings reveal major gaps in the knowledge on adolescents treated with external fixation for traumatic injury and none focused on EFD treatment in the acute period.

Biomechanical comparison of flexible stainless steel and titanium nails with external fixation using a femur fracture model

There are several options available for surgical stabilization of pediatric femoral shaft fractures. The purpose of this study was to compare the stability afforded by Ender stainless steel nails, titanium elastic nails, and one-plane unilateral external fixators for the fixation using a synthetic adolescent midshaft femur fracture model. The anterior-posterior (sagittal plane) bending, lateral (coronal plane) bending, torsional, and axial stiffness values were calculated using 6 different fixation configurations. These included pairs of 3.5-mm-diameter Ender nails with and without distal locking, 3.5- and 4.0-mm-diameter titanium elastic nails as well as single- and double-stacked monolateral external fixators. Eight synthetic femur models, 4 each with simulated transverse and comminuted fracture patterns, were sequentially tested for stability afforded by the various fracture fixation configurations. External fixation exhibited significantly greater control of anterior-posterior angulation compared with all flexible-nailing systems. Although Ender nails were slightly superior to titanium nails in control of sagittal plane angulation, this was not statistically significant. Compared with the external fixation constructs, all 4 flexible nail constructs demonstrated higher torsional stability. For prevention of axial shortening, all fixation methods were similar for the transverse fracture pattern, whereas external fixation was superior to flexible nails in the comminuted fracture model. No significant benefit was demonstrated with double stacking of external fixators. These findings may help guide clinicians choose the optimal fixation method for treatment of pediatric femoral shaft fractures.

[Management strategies in the first operative phase after long-bone injury of the lower extremity in multiple-injured patients. A systematic literature review]

OBJECTIVE

Lower extremity injuries make up a substantial proportion of the injuries in multiply injured patients. The aim of this systematic literature analysis was to give an overview of the levels of evidence for different management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients to enable, in the presence of adequate evidence, the development of clinical management corridors or, if the evidence was found to be inadequate, to document the necessity for scientific proof.

METHODS

Clinical trials were systematically collected (Medline, Cochrane and hand searches) and classified into evidence levels (EL 1 to 5 according to the Oxford system).

RESULTS

The necessity for primary or secondary definitive osteosynthesis of femur/tibia shaft fractures is still a matter of discussion. Intramedullary nailing is the preferred operative procedure for definitive treatment of femur shaft fractures. Stabilization of proximal and distal femur and tibia fractures is predominantly based on expert opinion. According to the literature, perioperative antibiotic prophylaxis is essential in fracture treatment.

CONCLUSION

Numerous comparative studies (EL 2) dealing with management strategies in the first operative phase after long-bone injuries of the lower extremity in multiply injured patients are available, but there are only a few randomized studies. Based on the available data, it is possible to develop a rational therapy for this patient population.

Can normal knee kinematics be restored with unicompartmental knee replacement?

BACKGROUND

Unicompartmental replacement can be an alternative to tibial osteotomy in younger, active patients with unicompartmental knee disease. In unicompartmental replacement, the other compartments and knee ligaments are largely untouched. Therefore, it was hypothesized that the knee kinematics after unicompartmental replacement may also be unchanged. To test this hypothesis, knee kinematics and quadriceps tension were recorded before and after replacement with a unicompartmental design and then with a tricompartmental design.

METHODS

Six human cadaver knees were tested before implantation, after implantation with a bicruciate-retaining unicompartmental knee prosthesis, and after implantation with a posterior cruciate-retaining tricompartmental knee prosthesis. The unicompartmental prosthesis was initially implanted, and it was then revised to a total condylar knee replacement. The knee kinematics were measured with use of an electromagnetic tracking device while the knee was put through dynamic simulated stair-climbing under peak flexion moments of approximately 40 N-m. Quadriceps tension was also measured for all three conditions.

RESULTS

No significant differences in tibial axial rotation were noted between the intact and unicompartmental conditions. However, tricompartmental replacement significantly affected tibial axial rotation (p = 0.001). Femoral rollback was not significantly affected by either unicompartmental or tricompartmental arthroplasty. Quadriceps tension was also similar among all three conditions.

CONCLUSIONS

In this in vitro cadaver study, the tricompartmental replacement significantly changed knee kinematics while the unicompartmental replacement preserved normal knee kinematics.

Treatment of femoral shaft fractures in young children: comparison between conservative treatment and retrograde flexible nailing

Outcomes of pediatric femoral fractures treated with traction followed by cast (conservative treatment) were compared with flexible nailing treatment. Fifty-one femoral fractures (24 conservative, 27 nail) from 46 patients were studied retrospectively. Four cases of angular deformities greater than 10 degree were observed from the conservative treatment and none from the nailing group. Conservative treatment showed a wider variance of leg length discrepancy (LLD) and four cases showed severe LLD greater than 10 mm. The nailing group had no discrepancy. Retrograde flexible nailing may result in more reliable outcomes than conservative treatment for femoral fractures.

Rotational control of various pediatric femur fractures stabilized with titanium elastic intramedullary nails

This study investigated the torsional stability of transverse, oblique, spiral, butterfly, and comminuted pediatric femur fractures reduced with titanium elastic nails. Twenty-five fractures were created in synthetic analog pediatric femora (five of each fracture type); each fracture was reduced with two 4-mm-diameter titanium elastic nails. Each reduced femur was tested for rotational stability using an MTS. Angular displacements and torques were recorded, plotted, and regressed, and the slope (torsional stiffness) was determined; analysis of variance was performed between fracture groups and rotational testing direction. The oblique fracture pattern exhibited the greatest torsional stiffness in internal rotation, the spiral fracture pattern the greatest stiffness in external rotation. All reduced fracture patterns possessed a torsional stiffness statistically equal to or greater than the torsional stiffness of the transverse fracture pattern. These results suggest this method of internal fixation provides a consistent means of rotational stability for a variety of fracture patterns in a synthetic model.

Biomechanical analysis of antegrade and retrograde flexible intramedullary nail fixation of pediatric femoral fractures using a synthetic bone model

Biomechanical testing was performed to evaluate the stability of simulated transverse and comminuted femoral fractures after retrograde and antegrade flexible titanium intramedullary nail fixation. Ten synthetic adolescent-sized femoral bone models were used. Five underwent retrograde fixation with two C-shaped nails inserted from medial and lateral entry portals. The other five underwent antegrade fixation using one C- and one S-shaped nail through lateral entry holes just inferior to the greater trochanter. Retrograde nail fixation demonstrated significantly less axial range of motion and greater torsional stiffness than antegrade fixation in both transverse and comminuted fracture patterns. However, there appeared to be a biomechanical trend of greater resistance to shortening for antegrade nails.

Rotational control of various pediatric femur fractures stabilized with titanium elastic intramedullary nails

This study investigated the torsional stability of transverse, oblique, spiral, butterfly, and comminuted pediatric femur fractures reduced with titanium elastic nails. Twenty-five fractures were created in synthetic analog pediatric femora (five of each fracture type); each fracture was reduced with two 4-mm-diameter titanium elastic nails. Each reduced femur was tested for rotational stability using an MTS. Angular displacements and torques were recorded, plotted, and regressed, and the slope (torsional stiffness) was determined; analysis of variance was performed between fracture groups and rotational testing direction. The oblique fracture pattern exhibited the greatest torsional stiffness in internal rotation, the spiral fracture pattern the greatest stiffness in external rotation. All reduced fracture patterns possessed a torsional stiffness statistically equal to or greater than the torsional stiffness of the transverse fracture pattern. These results suggest this method of internal fixation provides a consistent means of rotational stability for a variety of fracture patterns in a synthetic model.

Surgical treatment of pediatric femoral shaft fractures

PURPOSE OF REVIEW

Femoral shaft fractures are among the most common fractures in children. Depending on the patient's age, fracture location, pattern, mechanism of injury, and associated injuries, several different treatment options exist. The purpose of this review is to discuss these different clinical situations and the recommended treatment methods, as well as to characterize the latest literature and recommendations.

RECENT FINDINGS

In the past several years, there have been significant changes in the approach to the treatment of pediatric femoral shaft fractures, particularly in school-aged children. Young children have traditionally been treated conservatively with good results, and this method is still currently advocated. Adolescents over the age of 12 are generally treated with rigid intramedullary rods. However, in children between the ages of 5 and 12, new surgical treatment modalities have been tested with good outcomes, and, as new data emerge, these methods are becoming preferable to conservative treatment.

SUMMARY

Children who sustain femoral shaft fractures can present difficult challenges to both orthopedists and pediatricians. A recent shift in treatment in children between ages of 5 and 12 from nonoperative to surgical intervention has led to shorter hospital stays and earlier return to activity with reliable fracture healing.

Femoral shaft fractures in children: traction and casting versus elastic stable intramedullary nailing

BACKGROUND

Treatment of pediatric femoral fractures by 90/90 traction and spica casting (TXN/CST) has begun to be replaced by elastic stable intramedullary nailing (ESIN). The purpose of our study was to perform a cost analysis of TXN/CST versus ESIN in addition to comparing clinical/functional parameters.

METHODS

We reviewed all children admitted with femoral shaft fractures between January 1995 and April 1998. Overall cost and clinical/radiographic outcome measures were analyzed, and 60% of patients' parents completed a follow-up telephone interview. Sixty-eight patients representing 71 femoral shaft fractures that had complete data and 1-year follow-up were included.

RESULTS

No difference existed between the two groups for standard clinical/functional criteria. ESIN was associated with a lower overall cost than TXN/CST. ESIN also resulted in better scar acceptance, and higher overall parent satisfaction.

CONCLUSION

Less cost and comparable clinical outcome make ESIN a better option than traditional TXN/CST for femoral fracture care in the skeletally immature patient.

Social and economic benefits of flexible intramedullary nails in the treatment of pediatric femoral shaft fractures

All patients between the ages of 5 and 15 years with isolated femoral shaft fractures treated at our institution with flexible intramedullary nails between 1996 and 1998 were examined and compared to an age-matched group of patients treated with spica casting. All fractures healed well with no significant complications. Patients treated with flexible intramedullary nails achieved earlier independent ambulation, at an average of 19 days, compared to 106 in the control group (P<.0001). They also attained earlier independent bathroom use (21 versus 79 days, P<.0001). Hospital stays were significantly shorter as well (6 versus 29 days, P<.0001). These patients also returned to school earlier, at 28 days postinjury, compared to 120 days for patients in spica casts (P<.0001). The use of flexible intramedullaty nails allowed patients and their families to achieve independence months earlier than the spica cast patients. Earlier return to school, independent ambulation, and independent bathroom use are advantages of this treatment modality.

Immediate hip spica casting for femur fractures in pediatric patients. A review of 175 patients

Immediate closed reduction and application of a well-molded hip spica cast is a safe and effective treatment option for closed, isolated femur fractures in children who weigh between 10 and 100 pounds. Between 1988 and 1996, 190 immediate hip spica casts were placed on children with isolated femoral shaft fractures who weight between 10 and 100 pounds. Fifteen patients were lost to followup leaving 175 children who were evaluated and followed up for at least 2 years after the hip spica cast was removed (range 2-10 years). The femur fractures were reduced closed and placed in a 1 1/2 hip spica cast in the emergency room with the patient under conscious sedation or in the operating room with the patient under general anesthesia. All of the children returned home within 24 hours of the procedure. All 175 femur fractures united within 8 weeks. The only complication was a refracture in a 25 pound child who fell 1 week after the cast was removed. No significant residual angular deformities were present in any of the children at last followup. None of the children required external shoe lifts, epiphysiodesis, antibiotics, irrigation and debridements, or limb lengthening procedures for leg length inequalities. The authors think that immediate closed reduction and placement of a well-molded hip spica cast is a safe and reliable treatment option for isolated, closed femur fractures in children from birth to 10 years of age who weigh less than 80 pounds.

Early spica treatment of pediatric femoral shaft fractures

The purpose of this prospective study was to document results of early spica casting in treating all children aged 10 years or younger presenting during a 30-month period with a femoral shaft fracture. The outcome of 101 femoral shaft fractures thus treated demonstrated excellent results with few complications. Four spicas had to be removed at 7 to 10 days for unacceptable shortening and an additional four probably should have been. Control of alignment was not a problem, with only one patient's femur on cast removal being in a position different from that accepted at 7 to 10 days. An age older than 7 to 8 years is the only variable that might be used to predict the need for a change in treatment at 7 to 10 days.

Displaced fractures of the femoral shaft in children. Unique features and therapeutic options

The decision analysis for managing femoral shaft fractures in children should included such factors as the possibility of child abuse, overgrowth, and the potential for remodeling. Direct and indirect costs must be understood. Factors to consider in determining treatment include the age of the child, the extent of the soft tissue injury, and associated injuries. Non-operative methods, universally used in the past to treat these injuries, still are indicated, but operative modalities should be considered for a greater number of pediatric femoral fractures. Early enthusiasm for external fixation and rigid intramedullary rodding has been tempered by a greater awareness of their particular complications. The role of flexible intramedullary rodding, however, is expanding.

Paediatric trauma and resuscitation

Severe paediatric trauma differs from adult trauma in that blunt trauma, and especially head trauma, represents 98% of cases. In these instances, early control of the airways, prompt haemodynamic stabilization, emergency explorations and further conservative management of bleeding abdominal lesions are the most challenging issues. On-scene resuscitation, primary stabilization before transportation and transfer to a specialized centre are mandatory. The pre-hospital management of injured children, however, is frequently neglected. The need for emergency intubation and rapid intravenous access insertion is difficult to meet, in spite of many attempts to ameliorate this situation. The option of conservative surgical management of spleen and liver lesions has been extensively developed, and is now applied in many paediatric institutions with a high rate of success. A better application of on-scene resuscitation and of the selective management of bleeding lesions is the key to the prevention of secondary lesions, representing a major source of avoidable death and long-term sequelae.