Closed Ender nailing of femur fractures in older children

Flexible intramedullary nails with traction versus plaster cast for treating femoral shaft fractures in children: comparative retrospective study

CONTEXT AND OBJECTIVE Femoral fractures are common in children between 2 and 12 years of age, and 75% of the lesions affect the femoral shaft. Traction followed by a plaster cast is universally accepted as conservative treatment. However, in some situations, a surgical approach is recommended. The objective here was to compare treatments for femoral shaft fractures using intramedullary nails (titanium elastic nails, TEN) versus traction and plaster casts in children. The hypothesis was that TEN might provide better treatment, with good clinical results in comparison with plaster casts. DESIGN AND SETTING This retrospective comparative study was conducted in a public university hospital. METHODS Sixty children with femoral fractures were evaluated; 30 of them underwent surgical treatment with TEN and 30 were treated conservatively using plaster casts. The patients' ages ranged from 5 to 13 years (mean of 9 years). RESULTS The mean duration of hospitalization was nine days for the surgical group and 20 days for the conservative group. The incidence of overgrowth in the patients treated with TEN was 60.0% and, for those treated conservatively, 13.3%. Partial weight-bearing was allowed after 3.5 weeks in the surgical group and after 9.6 weeks in the conservative group. New hospitalization was required for 90.0% in the surgical group and 16.7% in the conservative group. Patients treated with plaster casts presented higher incidence of complications, such as loss of reduction. CONCLUSIONS The surgical method presented better results for children.

Treatment of femur fractures in school-aged children using elastic stable intramedullary nailing: a systematic review

Femur fractures are common long-bone injuries in school-aged children (6-12 years). Among the various acceptable treatment options, elastic stable intramedullary nailing (ESIN) has gained popularity over recent years although the level of evidence for ESIN is low. This study was a systematic review of the literature to examine the outcomes and complications of ESIN in school-aged children and to critically evaluate the quality of the available literature. Although most complications were minor, some series report complication rates of more than 50%. Union rates are high. Malunion or mechanical axis malalignment, on the other hand, is common, and leg length discrepancy and overgrowth are also not unusual. Symptomatic implants are common, particularly if the distal ends of the nail are left long and prominent. Refracture was noted to be uncommon in this population. ESIN is a well-accepted and reliable option for treatment of femur fractures in school-aged children. Advantages are decreased length of hospital stay, early return to function, and high union rates. Care must be taken to obtain and maintain reduction, and caution is advised in older and heavier children.

Short hospitalization period with elastic stable intramedullary nails in the treatment of femoral shaft fractures in school children

PURPOSE

To evaluate the safety and period of hospitalization of the treatment of femoral shaft fractures with titanium elastic nails (TEN) in the age range 5 to 14 years. The hypothesis was that TEN might be a low-cost treatment, with good clinical results and short length of hospitalization.

METHODS

Thirty children with femur fractures were surgically treated with TEN.

RESULTS

The patients spent an average of 9.4 days in hospital. The average period for the healing process was 7.7 weeks. Partial weight bearing was permitted 3.3 weeks after surgery. The incidence of overgrowth was 60%, with an average of 0.40 cm.

CONCLUSIONS

The surgical method brings few complications and results in good limb alignment, with a short period of hospitalization and early return to daily activities and school.

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

Femoral fractures represent about 2% of all fractures in childhood. Children with femoral fractures always need to be admitted to hospital and the use of resources is much higher than for other childhood fractures. During the past decade, there has been a trend towards surgical treatment of these fractures, one advantage being the shorter time required in hospital. Two common surgical treatment options are external fixation (EF) and elastic stable intramedullary nails (ESIN). Both methods have their advantages and disadvantages, and neither of them solves all of the problems. Used in a complementary manner, they are safe and reliable for the treatment of femoral fractures in children, and they give good long-term results and few serious complications.

A cost analysis of three methods of treating femoral shaft fractures in childrenA comparison of traction in hospital, traction in hospital/home and external fixation

INTRODUCTION

There is no consensus as to which is best treatment of femoral fractures in children.

PATIENTS AND METHODS

We performed a cost analysis comparing three treatments of femoral shaft fractures in children aged 3-15 years at 3 hospitals during the same period (1993-2000). The analysis included total medical costs and costs for the care provider and were calculated from the time of injury up to 1 year.

RESULTS

At hospital 1, treatment consisted of external fixation and early mobilization. At hospital 2, the treatment was skin or skeletal traction in hospital for 1-2 weeks, followed by home traction. At hospital 3, treatment was skin or skeletal traction in hospital until the fracture healed.

RESULTS

The average total costs per patient were EUR 10,000 at hospital 1, EUR 23,000 at hospital 2, and EUR 38,000 at hospital 3.

INTERPRETATION

The main factor for determining the cost of treatment was the number of days in hospital, which was lower in children treated with external fixation.

Antegrade intramedullary nailing of pediatric femoral fractures using an interlocking pediatric femoral nail and a lateral trochanteric entry point

BACKGROUND

The treatment of femoral shaft fractures in older children and adolescents using rigid intramedullary (IM) nail fixation offers the advantages of decreased soft tissue stripping, low incidence of malalignment, leg length discrepancy, early ambulation, and decreased hospital stay. Recent reports have described the development of osteonecrosis of the femoral head in children after IM nailing through the piriformis fossa and the tip of the greater trochanter. Others have noted secondary proximal femoral valgus and femoral neck narrowing after antegrade IM nailing. Using the lateral aspect of the greater \trochanter as the starting point avoids the tenuous blood supply of the proximal femur and did not seem to produce avascular necrosis or proximal femoral deformity in early reports.

METHODS

A retrospective clinical and radiographic review of 78 children and adolescents with 80 femoral shaft fractures who underwent IM nail fixation through the lateral aspect of the greater trochanter, with a mean follow-up of 99 weeks, was performed. Twenty-four fractures were observed until skeletal maturity. Final standing anteroposterior radiographs of both lower extremities were used to assess for evidence of osteonecrosis, limb length discrepancy, fracture alignment, and indices around the hips.

RESULTS

All patients went on to union in good clinical alignment without loss of reduction. No nonunions, delayed unions, or malunions were observed. Two patients developed infections postoperatively (2.5%). No patient had evidence of osteonecrosis of the femoral head. There was no significant difference in neck-shaft angle, articulotrochanteric distance, or femoral diameter when compared with the nonsurgical, normal side in these patients.

CONCLUSIONS

Intramedullary nail fixation through the lateral aspect of the greater trochanter in children and adolescents is effective. It does not produce clinically important femoral neck valgus or narrowing. We did not observe osteonecrosis of the femoral head.

LEVEL OF EVIDENCE

: Level IV, case series.

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.

Differences in biomechanical stability of femur fracture fixation when using titanium nails of increasing diameter

PURPOSE

The purpose of this study was to compare the biomechanical stability generated when utilizing increasing sizes of titanium (Ti) flexible nails for fixation of simulated comminuted femur fractures.

METHODS

Five synthetic adolescent-sized femur models were reamed to create a 9-mm canal. A 2-cm section was removed in the mid-diaphysis to simulate comminution. Each femur was first stabilized with bilateral, retrograde 3.0-mm titanium elastic nails. Femurs were tested in axial rotation and axial compression. The constructs were removed, and femurs were re-nailed with 3.5-mm nails. Identical testing was conducted. These nails were then removed, and femurs were re-nailed with 4.0-mm nails. This provided data on "canal fill" representing 67, 78 and 89% of the reamed canal diameter. Data for axial rotation (degrees) and failure load (N) required to produce 5 mm of fracture shortening were analyzed with a one-way ANOVA (P < 0.05) and a Tukey's post-hoc test for multiple comparisons.

RESULTS

For axial rotation, there were statistically significant improvements in rotational control for each increase in nail size. For axial stability, each increase in nail size resulted in increased axial failure loads to 5 mm, although these data were not statistically different. A specific comparison between 3.0- and 3.5-mm nails for compressive stability found significantly greater stability afforded by using 3.5-mm nails.

CONCLUSIONS

Data from this study demonstrate that increasing the amount of canal fill provides significant improvements in rotational control. The largest improvement was seen when increasing from 3.0- to 3.5-mm nails. While increasing the nail size from 3.5 to 4.0 mm again provided greater stability, larger nails may be more difficult to insert. Thus, increasing the nail size for femoral fracture fixation should be considered after measuring the diameter of the canal and evaluating the potential difficulty of insertion as well as specific demands of the fracture pattern.

Antegrade versus retrograde titanium elastic nail fixation of pediatric distal-third femoral-shaft fractures: a mechanical study

OBJECTIVES

To determine whether the stability of elastic stable intramedullary nail (ESIN) constructs differ in terms of antegrade versus retrograde insertion for the fixation of pediatric distal-third transverse femoral-shaft fractures.

METHODS

Ten synthetic composite adolescent-sized femur models and 20 flexible titanium (Ti) intramedullary (IM) nails were divided into antegrade and retrograde groups. A simulated transverse fracture was created in each of 10 models in the distal-third region of the shaft (more precisely near the distal fifth). The fractures were then stabilized with ESIN. The specimens were subjected to four-point bending and then axial torsion. Flexural forces were applied to the medial aspect of the model across the fracture site at a rate of 0.05 mm/s to a maximum displacement of 3.7 mm (7 degrees). Torsional moments were applied to the distal aspect of the model in internal and external rotation at a rate of 0.75 degrees/s to a maximum of 10 degrees. Loads and stiffnesses were determined between consistent displacement limits; differences were compared using t tests (alpha = 0.05, two tailed).

RESULTS

Flexural stiffness was significantly greater in the retrograde group (350 +/- 72 N/mm) compared with antegrade (195 +/- 95 N/mm; P = 0.02). A 66-kg load placed across the fracture displaced the site 3.7 mm for the antegrade group, whereas the retrograde group required a load 89% greater (125 kg). Although torsional stiffness tended to be greater in the antegrade group, the differences were not statistically significant (P = 0.2).

CONCLUSIONS

Although the recommendation for distal-third femur fractures is antegrade nail insertion, this study demonstrates that given satisfactory cortical starting points in the distal fragment, retrograde insertion provides greater stability. These mechanical testing data are the first to address this specific fracture scenario and may aid surgical decision making.

Treatment of femoral shaft fractures in children using intramedullary Kirschner wire pinning

From 1996 to 2002 we used intramedullary Kirschner wires to treat 19 femoral shaft fractures in 19 children (11 boys, 8 girls). Their ages ranged from 2 to 13 years (mean 5.8 years). The mean follow-up time was 3 years (range 4 months to 4 years 9 months). The technique was intramedullary pinning using a 2.5- to 3.0-mm Kirschner wire introduced through the greater trochanter followed by spica casting. All cases achieved bone union within 3 months. The mean angular deformity was 1.7 degrees (range 0 degrees -5 degrees ), and one patient had an external rotational deformity. The mean overgrowth was 7.5 mm, but no patient had residual problems during activities of daily living. Our method has the following advantages: no need of traction, leaving bed earlier, ease of nursing, fewer radiographic examinations, less angular deformity. It also has several disadvantages: the need for an operation under general anesthesia, the need for metal removal, and an operation scar. This method can be considered as one option for treating femoral shaft fractures in children.

The locked flexible intramedullary humerus nail in pediatric femur and tibia shaft fractures: a feasibility study

There are several options for the treatment of long bone fractures in skeletally immature patients. Surgeon experience, type of fracture, and the possibility of damage to the physeal area dictate individual fracture management patterns. Notably, nail devices have not gained popularity in this patient group. Intramedullary locking nails have become the standard of care in adult patients due to decreased morbidity and mortality. A novel nail has been developed for humeral shaft fractures that uses a lateral starting position to avoid damage to the rotator cuff in humeral fracture fixation. This is possible because of the nail's transient flexibility during insertion. This study illustrates that it is feasible to insert this type of nail through multiple entry portals for both tibial and femoral fracture fixation, without damaging the physeal blood supply or growth areas.

Femoral shaft fractures in children: elastic stable intramedullary nailing in 31 cases

We report our experience with elastic stable intramedullary titanium nailing (ESIN) of femoral shaft fractures in children. From 1998 to 2001, we treated 31 children (20 boys), median age 6 (4-11) years, with ESIN for 29 closed and 2 grade I open femoral shaft fractures. We reviewed 30 children clinically after median 1.5 (1-3) years. Their median hospital stay was 6 (2-20) days. All fractures were radiographically united at a median of 7 (5-9) weeks. The nails were removed in 29 children after a median of 22 (6-38) weeks postoperatively. At follow-up, we found a leg-length discrepancy up to 1 cm in 6 children and 10 degrees of internal rotational deformity in 1 child. No angular deformity had occurred. Elastic stable intramedullary nailing seems to be a safe method for the treatment of femoral shaft fractures in children between 4 and 11 years of age.

Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: preliminary results of a new technique in 15 children

OBJECTIVES

To evaluate the clinical results of intramedullary nailing of femoral shaft fractures using a rigid intramedullary nail placed through the lateral aspect of the greater trochanter in older children and adolescents.

DESIGN

A retrospective study was carried out evaluating all skeletally immature patients with femoral shaft fractures treated using a modified rigid humeral intramedullary nail.

PATIENTS/PARTICIPANTS

Fifteen children and adolescents with displaced femoral diaphyseal fractures and open physes.

INTERVENTION

Femoral shaft fractures in children and adolescents were stabilized using a modified humeral intramedullary nail placed through the lateral aspect of the greater trochanter.

MAIN OUTCOME MEASUREMENTS

Patients were evaluated to determine time to union, final fracture alignment, hospital stay, complications, clinical outcome, and proximal femoral changes including avascular necrosis or proximal femoral valgus with femoral neck narrowing.

RESULTS

Fifteen patients were followed for a minimum of 1 year (range 70-157 weeks). The average age of the patients was 12 years and 5 months (range 8 years and 2 months-17 years and 1 month). All fractures healed at a mean of 7 weeks (range 5-14 weeks) after fracture. The average hospital stay for patients with isolated femur fractures (8/15) was 2.8 days (range 1-5 days). At an average follow-up of 141 weeks (range 70-326 weeks), no patient had developed avascular necrosis, femoral neck valgus, femoral neck narrowing, or other complications.

CONCLUSIONS

The technique of intramedullary nailing in children through the lateral aspect of the greater trochanter seems to be safe, effective, and well tolerated by patients.

External fixation of displaced femoral shaft fractures in children: a consecutive study of 98 fractures

OBJECTIVE

To evaluate unilateral external fixation when applied as the standard treatment of children with displaced femoral shaft fractures.

SETTING

Two county hospitals in central Sweden.

DESIGN

A consecutive and prospective study including all children aged 3 to 15 years with displaced femoral fractures admitted to either of the two hospitals. Patients were followed clinically and radiographically until healing and at 1 year.

RESULTS

A total of 96 children with 98 fractures were treated with the same kind of external fixator during the period 1993-2000. The mean age was 8.1 years (range 3-15 years). Average hospital stay was 8.7 days (median 7 days). Average time of external fixation was 61 days (range 37-127 days; median 56 days). Minor complications included pin track inflammation/infection in 36 of 98 (37%) fractures. In 18 of 36 fractures, a short treatment with oral antibiotics was given. Other minor complications were one heterotopic ossification, one patient with two rereductions, nine cases of clinically insignificant malunion (varus = valgus > 5 degrees or procurvatum > 10 degrees ), and one leg-length discrepancy greater than 2 cm. Major complications (6%) included two refractures, one through a pinhole and one at the fracture site, both after significant trauma. Three of the older children with transverse fractures after high-energy injury developed a bending due to premature removal of the fixator prior to healing and required corrective osteotomies. One boy had a third rereduction because of displacement after a fall.

CONCLUSIONS

The use of external fixation as a standard treatment of uncomplicated displaced femoral shaft fractures in children gave satisfactory results. The surgical learning curve was short, and the advantages compared with nonsurgical treatment included shorter hospital stay, early mobilization, and fewer days out of school for the patient and out of work for the caregiver. We believe that the advantages far outweigh the complications, many of which can be avoided.

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.

Ender rod fixation of femoral shaft fractures in children

Ender rod fixation for femoral shaft fractures in children was evaluated in a prospective study at two Level 1 trauma centers. Fifty-seven fractures in 52 patients were evaluated. Criteria for inclusion in the study included age younger than 14 years, femoral shaft fractures occurring in the middle 3/5, canal size greater than 7 mm, and parental consent. Hip and knee motion, gait, leg length discrepancy, and rotational asymmetry were evaluated by clinical examination. Standard radiographs were used to measure any residual angulation. A subset of patients whose injuries occurred more than 12 months previously was evaluated using scanograms. Followup averaged 20 months. There were no delayed unions and all fractures healed within 12 weeks. Clinically significant leg length discrepancy, malunion, or loss of motion did not occur. Functional results were excellent and complications were minor. Ender rod fixation of femur fractures in children allows the advantages of surgical fixation with minimal risk of complications.

Treatment of femoral shaft fractures in children by intramedullary Kirschner wires

BACKGROUND

We present a retrospective analysis of a case series to evaluate closed intramedullary Kirschner wire (K-wire) fixation as a surgical technique in the treatment of femoral shaft fractures in children.

METHODS

Fifty-three femoral shaft fractures (at various levels) were fixed by using closed intramedullary K-wires. The patient was placed supine on an orthopedic traction table. Under fluoroscopic control, two K-wires (2.5-3.5 mm thick) were introduced from distal metaphysis to the proximal metaphysis, one each, from medial and lateral cortices. In three distal fractures, K-wires were inserted antegrade from the proximal to distal metaphysis through the lateral cortex. Early mobilization and weight bearing was allowed. Mean hospital stay was 6.5 days, and K-wires were removed after a mean of 5.6 months. The study included seven open fractures as well.

RESULTS

Sound unions were achieved between 6 and 10 weeks without any significant complication.

CONCLUSION

Closed intramedullary K-wire fixation for femoral shaft fractures in children is a simple surgical technique that has excellent clinical and functional results.

Elastic stable intramedullary nailing for unstable femoral fractures in children: preliminary results of a new method

BACKGROUND

Many femoral fracture patterns in children cannot be stabilized sufficiently by intramedullary nailing only. Such fractures may require additional cast bracing or cerclage wiring after nailing. To overcome this problem, pediatric Ender nails that can be interlocked were designed to achieve better fracture stabilization.

METHOD

Seventeen children (age, 2.5 to 15 years) were treated with this method for unstable traumatic fractures of the femur. The average follow-up period was 11.8 months.

RESULTS

All fractures healed within 4 weeks in the mean. There were no major complications.

CONCLUSION

This new method prevents shortening and axial deviation of the fractured femur. Start of postoperative mobilization and increase of weight-bearing is mainly determined by the child.

Femoral shaft fractures in children treated by closed reduction and early spica cast with incorporated supracondylar Kirschner wires: a long-term follow-up results

38 children between 1 and 10 years of age with femoral shaft fractures were treated by closed reduction and early spica cast with incorporated supracondylar Kirschner wires and followed up prospectively. Overrides of maximum 15 mm, medial and anterior angulations less than 15 degrees and lateral angulation up to 5 degrees were considered acceptable. Posterior angulation and malrotation were not accepted. Of the 38 children examined at a mean of 65.6 months (range, 58-80 months) after fracture, none had any residual skeletal deformity and joint stiffness. At long-term follow-up, maximal shortening was 11 mm and overgrowth was 6 mm. The only factor associated with unacceptable shortening was shortening > 15 mm at the time of spica cast application. We believe that close follow-up during the first 3 weeks after cast application is important in order to achieve an acceptable final outcome. On the other hand this method of treatment is simple, safe and effective. It dramatically decreases hospital stay and cost of treatment and allows rapid return of the patients to their family environment.

Skeletal traction versus external fixation for pediatric femoral shaft fractures: a comparison of hospital costs and charges

OBJECTIVES

To compare the hospital costs, charges, and reimbursement for treatment of pediatric femur fractures by two treatment methods: external fixation and 90-90 traction with spica casting.

DESIGN

Retrospective clinical review.

SETTING

Department of Orthopaedic Surgery, Children's Hospital Oakland, regional pediatric trauma center.

PATIENTS

Twenty-nine consecutive patients between the ages of five and ten with a fracture of the femoral shaft were treated by one of two methods: external fixation (sixteen patients) or 90-90 skeletal traction followed by spica casting (thirteen patients).

INTERVENTION

External fixation or 90-90 traction followed by spica casting.

MAIN OUTCOME MEASURE

Hospital billing data including costs, charges, reimbursement for the initial inpatient hospitalization, and outpatient financial data until fracture union and cessation of treatment.

RESULTS

There was no difference in age, total treatment time, mechanism of injury, or number of associated injuries between the two groups. The average charge for treatment with skeletal traction and spica casting was $32,094 per patient versus $21,439 for external fixation (p < 0.001). The average cost for treatment with traction and spica casting was $22,396 per patient versus $11,520 for external fixation (p < 0.001); reimbursement was $30,846 and $7,490, respectively (p < 0.001). The number of days in the hospital was larger for the traction group than for the external fixation group (22.3 days versus 4.7 days, p < 0.0001).

CONCLUSIONS

External fixation of pediatric femoral shaft fractures results in decreased hospital costs and length of hospitalization, but produces significantly less income for the hospital when compared with skeletal traction followed by spica casting.

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

Healthcare cost containment and a desire for early discharge of the pediatric patient to the home environment have become important factors in the treatment of femoral shaft fractures in children. As a result, newer techniques of treatment have become popular. The immediate hip spica cast remains the primary method of treatment for most children 6 years of age and younger. The treatment for children between the ages of 6 and 10 years is the most controversial. Many such patients may be treated successfully with immediate hip spica casts. However, external fixation and flexible intramedullary rod fixation are being used more frequently, particularly in patients with multiple trauma. The initial enthusiasm for rigid intramedullary rod fixation of adolescent femoral fractures has been tempered by recent reports of femoral head avascular necrosis. Avoiding the piriformis fossa during rod insertion may prevent this complication. Most children and adolescents with femoral fractures can be treated successfully with a brief hospital course without compromising care or outcome.

Flexible intramedullary nail fixation of pediatric femoral fractures

The management of pediatric femoral shaft fractures gradually has evolved toward a more operative approach in the past decade. This is because of a desire for more rapid recovery and reintegration of the patients, and a recognition that prolonged immobilization can have negative effects even in children. Economic pressures also favor a treatment that does not require as prolonged a hospitalization as that required with the traditional traction method. External fixation, compression plating, and intramedullary nailing all have been advocated. A retrospective review of the experience with antegrade flexible intramedullary nailing in 25 children was performed. No nonunions or significant malunions were seen. Followup evaluation of limb lengths and proximal femoral morphology showed minor variations of articulotrochanteric distance and neck shaft angle, none of which were clinically significant. Likewise, minor limb length discrepancies were measured (range, -11- +14 mm) with no consistent pattern of overgrowth noted. There was no evidence of a complete trochanteric growth arrest on radiographic followup. Flexible intramedullary nailing seems to be a safe and effective method for the treatment of femoral shaft fractures in the child between 6 and 12 years of age.

Orthoses and prostheses

Orthoses and prostheses include a wide range of devices and strategies for correcting and alleviating dysfunction and disability. Features in these areas of technology include continuing evolution of new devices, further development of well-established approaches, a need for critical assessment, requirements for support from technical and health care workers, and the need to identify funding to achieve efficient programs.

Closed Ender nailing of adolescent femoral shaft fractures

Twenty-seven adolescents with 29 femoral shaft fractures, between the ages of 10 and 16 years, were treated with closed flexible Ender intramedullary nailing from 1989 to 1992 in our clinic. In one patient who had a fracture of the distal third of the femoral shaft, the nail was inserted proximal to distal (antegrade nailing). In the other patients, the nails were inserted distal to proximal (retrograde nailing). Clinical and radiological follow up averaged 32 months (18-56 months). Hospitalization averaged 15 days (7-28 days). All fractures healed with one significant leg length discrepancy of 1.7 cm in a patient who had developed osteomyelitis. There was no significant angulation or malrotation. All patients had a normal gait and were able to participate in full activities. There was one deep wound infection in a patient with an open fracture of the femoral shaft. There were no non-unions, delayed-unions or psychological complications. For this age group, this treatment of femoral shaft fracture should be considered owing to the functional recovery with low morbidity and cost, providing early ambulation, early discharge from hospital and early return to school.