Closed, Locked Intramedullary Nailing of Pediatric Femoral Shaft Fractures Through the Tip of the Greater Trochanter

Treatment of Length-Unstable Pediatric Femur Fractures in Children Aged 5 to 11 years: A Focused Review

Pediatric femur fractures in children aged 5 to 11 years are typically classified as length-stable versus length-unstable. For length-stable fracture patterns, there is frequent consensus among pediatric orthopaedic specialists regarding the appropriateness of flexible intramedullary nails, submuscular plates (SMP), or lateral-entry rigid intramedullary nails (LE-RIMN). With length-unstable fracture patterns, however, the decision is more complex. Age, weight, fracture pattern, fracture location, surgical technique, surgeon experience, several implant-specific details, and additional factors are all important when choosing between flexible intramedullary nail, SMP, and LE-RIMN. These familiar methods of fixation may all be supported by conflicting and sometimes heterogeneous data. When planning to treat length-unstable fractures in young children, surgeons should understand evidence-based details associated with each implant and how each patient-specific scenario affects perioperative decisions.

Pediatric femoral shaft fracture requiring revision surgery for nonunion associated with vitamin D and K deficiencies: a case report

BACKGROUND

Nonunion of femoral shaft fractures in children is rare, and there is no clear treatment protocol. In this case report, a pediatric femoral shaft fracture that developed in nonunion due to vitamin deficiency after osteosynthesis, which was successfully treated with vitamin augmentation and replacement with a rigid antegrade intramedullary nail, is described.

CASE PRESENTATION

The patient is an 11-year-old Japanese girl. She injured her right femoral shaft fracture when she hit a wall after kickboarding down a hill and underwent osteosynthesis with a titanium elastic nail. Six months postoperatively, she developed nonunion, was found to be deficient in vitamins D and K, and was started on vitamin supplementation. She underwent replacement with a rigid antegrade intramedullary nail at 7 months postoperatively, and bone union was achieved 3 months after reoperation.

CONCLUSION

When delayed union of a fracture is observed postoperatively, even in children without underlying disease, the cause of the problem must be investigated and treated promptly.

Intramedullary Fixation for Pediatric Femoral Nonunion in Low- and Middle-Income Countries

BACKGROUND

Pediatric femoral shaft nonunion after use of a plate or intramedullary nail (IMN) is uncommon in the United States. In low and middle-income countries, as defined by The World Bank, these complications may occur with greater frequency. We assessed the rates of union and painless weight-bearing after IMN fixation of pediatric femoral shaft nonunion in lower-resource settings.

METHODS

We queried the SIGN (Surgical Implant Generation Network) Fracture Care International online database to identify all pediatric femoral shaft nonunions that had occurred since 2003 and had ≥3 months of follow-up after their treatment; our query identified 85 fractures in 83 patients. We defined nonunion as failure of initial instrumentation >90 days following its placement, lack of radiographic progression on radiographs made >3 months apart, or the absence of signs of radiographic healing >6 months after initial instrumentation. We evaluated the most recent follow-up radiograph to determine a Radiographic Union Scale in Tibial fractures (RUST) score. We also recorded rates of painless full weight-bearing as assessed by the treating surgeon.

RESULTS

Fifty-seven patients with pediatric femoral shaft nonunions (including 42 male and 15 female patients from 18 countries) were included. The average age (and standard deviation) at the time of revision surgery was 13.8 ± 3.0 years (range, 6 to 17 years). The median duration of follow-up was 67 weeks (range, 13 weeks to 7.7 years). The initial instrumentation that went on to implant failure included plate constructs (56%), non-SIGN IMNs (40%), and SIGN IMNs (4%). At the time of the latest follow-up, 52 patients (91%) had a RUST score of ≥10 and 51 (89%) had painless full weight-bearing. No patient had radiographic evidence of femoral head osteonecrosis at the time of complete fracture-healing or the latest follow-up.

CONCLUSIONS

Pediatric femoral shaft nonunion can occur after both plate and IMN fixation in low and middle-income countries. IMN fixation is an effective and safe treatment for these injuries.

LEVEL OF EVIDENCE

Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Ipsilateral femoral neck and shaft fracture in children: Two case reports

RATIONALE

Pediatric femoral shaft combined with ipsilateral femoral neck fractures are very rare but challenging injuries fraught with the development of avascular necrosis, coxa vara, and leg length discrepancy. Majority of the previous reports indicated the neck femur fracture was fixed with cannulated screws or/and pins, femoral shaft fracture was stabilized with a plate and screws. However, we used cannulated screws combined with elastic stable intramedullary nails to minimally invasive procedures treat this type of injury and achieved good follow-up results.

PATIENT CONCERNS

A 7-year-old boy (Case 1) was hospitalized due to a traffic accident resulting in swelling and deformity of the right thigh accompanied by limited mobility of hip and knee. A 5-year-old male child (Case 2) presented with pain and swelling in the bilateral lower limb after fall from approximately 12 feet.

DIAGNOSES

Physical examination, X-ray film, and computed tomography were performed. Both patients were diagnosed with ipsilateral femoral neck and shaft fracture.

INTERVENTIONS

The fractures were reduced closed by image-intensifier imaging. Two partially threaded cancellous screws were used to fix femoral neck fracture, and elastic intramedullary nails were performed to stable the femoral shaft fracture. Postoperatively, the patients were immobilized in a one-and-a-half hip spica cast for six weeks. The internal fixations were removed after one year.

OUTCOMES

Case one was follow-up at 14 months and the other one was followed up for 3 years. And at the last follow-up showed a normal and painless hip function. No clinical complications were found during follow-up visit, including head penetration, implant failure, fracture nonunion, avascular necrosis and hip varus deformity.

LESSONS

Clinician should carefully check and read relevant imaging data to avoid missed diagnosis. And the internal fixation method described in this paper may be more minimally invasive.

Decreased Radiation Exposure Using Ultrasound-Assisted Reduction and Fixation of Femoral Shaft Fractures in Children: A Pilot Study

Elastic stable intra-medullary nail procedures have been used to treat femoral fractures in children for some time. Radiation exposure generated by intra-operative radioscopy may induce side effects in children and staff. This study introduces a method of ultrasound-assisted reduction and fixation of femoral fractures in children to decrease radiation exposure. We included 21 children and evaluated displacement of fractures using multi-section scanning. All fracture reductions were performed with ultrasonography. A hyperechoic point with a posterior acoustic shadow can be seen under the proximal and distal segments after the nail passes through the fracture site. Comparison with radioscopy suggests that this is a viable method of reduction and fixation of femoral shaft fractures in children, and can effectively decrease radiation exposure.

V, RHH A, Khurana A. Current Concepts in Paediatric Femoral Shaft Fractures

Pediatric femoral shaft fractures account for less than 2% of all fractures in children. However, these are the most common pediatric fractures necessitating hospitalization and are associated with prolonged hospital stay, prolonged immobilization and impose a significant burden on the healthcare system as well as caregivers. In this paper, the authors present a comprehensive review of epidemiology, aetiology, classification and managemement options of pediatric femoral shaft fractures.

An Anatomic Study of the Greater Trochanter Starting Point for Intramedullary Nailing in the Skeletally Immature

BACKGROUND

Trochanteric entry femoral nails have been increasing in popularity in the pediatric population for stabilization in fractures and osteotomies. The proper position for entry point in the coronal plane has been well studied; however, the sagittal plane in the pediatric population has not yet been well characterized.

METHODS

Eighty-eight cadaveric femora aged 8 to 20 years were studied in an apparent neck-shaft angle (ANSA) position, with distal condyles flat on the surface, and a true neck-shaft angle (TNSA) position, with internal rotation to neutralize femoral anteversion. Anterior and lateral offset were measured on lateral and anteroposterior photographs, respectively, as the perpendicular distance from the greater trochanter apex to the center of the intramedullary canal. The effect of rotational position (ANSA vs. TNSA) of the proximal femur was compared using the intraclass correlation coefficient for anterior and lateral offset. Correlations between age, demographics, anteversion, and greater trochanter morphology with anterior and lateral offset were evaluated with multiple regression analysis.

RESULTS

The mean age was 15.8±3.8 years. The mean anterior displacement of the trochanteric apex was 4.8±3.0 and 4.6±3.2 mm in the ANSA and TNSA positions, respectively. The mean lateral displacement was 10.6±4.2 and 9.7±4.0 mm in the ANSA and TNSA positions, respectively. The intraclass coefficient for anterior offset in the ANSA versus TNSA position was 0.704 and 0.900 for lateral offset. Change was minimal for anterior offset in the ANSA and TNSA positions versus age (standardized beta values 0.240, 0.241, respectively). There was a significant correlation with increasing lateral offset in the ANSA and TNSA positions with increasing age (standardized beta values 0.500, 0.385 respectively).

CONCLUSIONS

In the pediatric population, the tip of the greater trochanter is consistently anterior by approximately 5 mm. The mean lateral displacement was approximately 10 mm and increased with increasing age.

CLINICAL RELEVANCE

Nail entry at the pediatric greater trochanter apex would likely result in anterior placement. We recommend inserting the guidewire 5 mm posterior to the apex of the trochanter and confirming coronal and sagittal position with fluoroscopy.

Clinical outcomes and complications of titanium versus stainless steel elastic nail in management of paediatric femoral fractures-a systematic review

Femoral shaft fractures in children account for approximately 1.6% of all fractures. These fractures can be treated both operatively and non-operatively. Surgical fixation is more common in the age group above 6 years. Elastic intramedullary nails have become the most popular surgical modality of treatment over the last few decades. However, there is continuous debate about which type of elastic nails (titanium and stainless steel) provides better clinical outcomes with less complication. The main purpose of this study was to systematically search for and critically appraise articles comparing clinical outcomes and complications of titanium elastic nail system (TENS) and stainless steel elastic nail system (SSENS) in management of femoral fractures in the paediatric age group. A comprehensive search of MEDLINE, EMBASE, and Cochrane library databases was performed using specific search terms and limits. Applying strict eligibility criteria, the identified studies were screened. Five studies were identified and reviewed. All of the identified studies were non-randomised comparative studies apart from one randomised controlled study. Studies provide contradictory evidence with regard to time to fracture union and time to full weight bearing. Only one study commented on time to nail removal and found that it is shorter in the TENS group. Two studies showed significantly higher rate of malunion in the TENS group, whereas the rest showed no difference. There was no difference in the rates of delayed union or infection between the two groups and no consistent difference in the rates of skin irritation. Three studies compared Flynn's outcome score and found no difference apart from one study which found better scores in the SSENS group. There is no consistent evidence to indicate the advantage of one type of elastic nails over the other in management of paediatric femoral shaft fractures; however, the overall trend is in favour of SSENS especially being cheaper than TENS. Critical appraisal of the studies identified significant methodological deficiencies, and further prospective randomised trials are recommended for more potent evidence.

Pediatric Diaphyseal Femur Fractures: Submuscular Plating Compared With Intramedullary Nailing

This study compared the radiographic and clinical outcomes of pediatric diaphyseal femur fractures treated by submuscular plating, flexible retrograde intramedullary nailing, or rigid antegrade intramedullary nailing with a trochanteric entry point in skeletally immature patients who were 8 years and older. A retrospective review was conducted of skeletally immature patients 8 years and older who were treated for femur fracture with submuscular plating, flexible intramedullary nailing, or rigid intramedullary nailing from 2001 to 2014 with a minimum 12-week follow-up. Treatment outcomes were compared for statistical significance, including time to union, malunion, nonunion, heterotopic ossification, avascular necrosis, time to full weight bearing, limb length discrepancy, residual limp, painful hardware, and infection. The study identified 198 femur fractures in 196 patients (mean age, 11.9 years). Each femur fracture was treated with submuscular plating (35), flexible intramedullary nailing (61), or rigid intramedullary nailing (102). Mean follow-up across the cohort was 48 weeks, ranging from 12 to 225 weeks. Flexible nailing was associated with an increased incidence of malunion (P<.0001) and hardware irritation (P=.0204) and longer time to full weight bearing (P=.0018). Rigid nailing was associated with an increased incidence of limp at 12-week followup (P=.0412). Additionally, 23.5% of patients who were treated with rigid nailing had heterotopic ossification. Of all surgical methods, submuscular plating allowed for the most rapid return to full weight bearing (mean, 7 weeks) and offered the fastest healing rate (mean, 6 weeks). Submuscular plating resulted in faster times to union and full weight bearing, with minimal complication rates. Rigid intramedullary nailing with trochanteric entry resulted in a lower incidence of malunion and hardware-related complications; however, these patients had an increased incidence of heterotopic ossification and residual limp postoperatively. Flexible retrograde intramedullary nailing resulted in the highest rates of malunion and hardware irritation and the longest time to full weight bearing. [Orthopedics. 2016; 39(6):353-358.].

The management of paediatric diaphyseal femoral fractures: a modern approach

The definitive treatment of paediatric femoral diaphyseal fractures remains controversial. Modalities of treatment vary mostly according to age, with fracture pattern and site having a lesser impact. Current evidence is reflective of this variation with most evidence cited by the American Academy of Orthopedic Surgeons being level 4 or 5. The authors present a review of the most up-to-date evidence relating to the treatment of these fractures in each age group. In an attempt to clarify the current trends, we have produced an algorithm for decision-making based on the experience from our own tertiary referral level 1 major trauma centre.

Percutaneous rotational osteotomy of the femur utilizing an intramedullary rod

The purpose is to describe the technique and report the results and complications of percutaneous femoral rotational osteotomy, secured with a trochanteric-entry, locked intramedullary rod, in adolescents with femoral anteversion. Our series comprised an IRB approved, retrospective, consecutive series of 85 osteotomies (57 patients), followed to implant removal. The average age at surgery was 13.3 years (range 8.8–18.3) with a female-to-male ratio of 2.8:1. The minimum follow-up was 2 years. Eighty-three osteotomies healed primarily. Two patients, subsequently found to have vitamin D deficiency, broke screws and developed nonunions; both healed after repeat reaming and rod exchange and vitamin supplementation. Preoperative symptoms, including in-toeing gait, tripping and anterior knee pain or patellar instability, were resolved consistently. We did not observe significant growth disturbance or osteonecrosis. We noted a 12.5 % incidence of broken interlocking screws; this did not affect the correction or outcome except for the two patients mentioned above. This prompted a switch from a standard screw (core diameter = 3 mm) to a threaded bolt (core diameter = 3.7 mm). These results have led this technique to replace the use of plates or blade plates for rotational osteotomies.

Interlocking intramedullary nail fixation with additional bone grafting from trochanter via a femoral hollow trephine in the treatment of femoral shaft fractures: design and clinical application

PURPOSE

The purpose of this study was to describe and evaluate the clinical application of the technique of interlocking intramedullary (IM) nailing via an entry point at the tip of greater trochanter using a specially designed femoral hollow trephine to stabilize diaphyseal fractures of the femur.

METHODS

From February 2010 to April 2014, 35 consecutive patients with femoral shaft fractures were treated by the therapy of bone grafting from trochanter region with interlocking IM nail. The average age of these 23 male and 12 female patients was 37.5 years (range, 22-67 years). Fractures were classified according to AO classification system (15 type A, 17 type B, 3 type C). Femoral canal reaming and the collection of cancellous bone were simultaneously performed in a single step with the specially designed femoral hollow trephine, followed by regular IM nailing procedure.

RESULTS

Of the 35 cases, the mean volume of spongy bone obtained was 5.63 cm³ (range, 3.0-7.0 cm³). Thirty-five patients with femoral shaft fractures had a mean follow-up period of 16.2 months (range, 12-22 months). All patients achieved bony union, at a mean of 5.4 months (range, 4-6 months). No patient developed a delayed union or a nonunion. There were no complications such as infections, injury of vascular and nerve, or heterotopic ossification in hip.

CONCLUSIONS

These results indicate that the technique of use of IM nailing with the femoral hollow trephine significantly decreases the occurrence of nonunion in femoral shaft fractures.

Changing trends in the management of children's fractures

The management of children's fractures has evolved as a result of better health education, changes in lifestyle, improved implant technology and the changing expectations of society. This review focuses on the changes seen in paediatric fractures, including epidemiology, the increasing problems of obesity, the mechanisms of injury, non-accidental injuries and litigation. We also examine the changes in the management of fractures at three specific sites: the supracondylar humerus, femoral shaft and forearm. There has been an increasing trend towards surgical stabilisation of these fractures. The reasons for this are multifactorial, including societal expectations of a perfect result and reduced hospital stay. Reduced hospital stay is beneficial to the social, educational and psychological needs of the child and beneficial to society as a whole, due to reduced costs.

Comparison of SIGN Pediatric and Fin nails in pediatric diaphyseal femur fractures: early clinical results

OBJECTIVES

The purpose of this study was to evaluate the effectiveness of SIGN Pediatric and Fin nails in treating pediatric diaphyseal femur fractures.

DESIGN

Prospective case series.

SETTING

Level I trauma center from 2010 to 2013.

PATIENT/PARTICIPANTS

Eighteen patients (13 male and 5 female) with pediatric diaphyseal femur fractures who did not achieve skeletal maturity.

INTERVENTION

Femoral nailing was done using either SIGN Pediatric or Fin nail with hand-reaming without using bone-grafting or image intensifier.

MAIN OUTCOME MEASUREMENTS

Patients were evaluated for infection, radiographic parameters, range of movements, time to weight-bearing (partial and complete), revision surgery (if needed), and complications.

RESULTS

The average age of patients was 10.2 (±2.1) (range: 6-13) years and average time between injury and surgery was 13 (1-112) days. Fin nail was used in 13 patients, and Pediatric nail in 5 patients. There were no infections in either group. The average time for full weight-bearing was 7.07 weeks in the Fin nail group, and 8.4 weeks in the Pediatric nail group. No repeat surgeries were performed, and there was no case of avascular necrosis of femur head, limb length discrepancy, or any other complication.

CONCLUSIONS

SIGN Pediatric and Fin nails are an effective treatment modality for pediatric diaphyseal femur fractures with excellent fracture healing with no major complications.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients Using a Lateral Trochanteric Entry Portal

Introduction

We describe rigid intramedullary nailing using a trochanteric entry for internal fixation of femoral shaft fractures in older children and adolescents.

Step 1 Preparation Prior to Incision

Appropriate preparation prior to the operation is key to minimizing intraoperative and postoperative complications.

Step 2 Perform Incision and Exposure

A well-positioned incision will facilitate and reduce difficulty with ideal guidewire placement.

Step 3 Place and Overream the Guide Pin

Ensure that the guide pin is properly positioned on the greater trochanter, while avoiding the piriformis fossa.

Step 4 Place the Guidewire and Reduce the Fracture

Prepare the definitive guidewire. Insert the guidewire into the proximal fragment via the trochanteric portal. While maintaining the fracture reduction, advance the guidewire into the distal fragment.

Step 5 Measure Nail Length and Begin Overreaming

Pay careful attention to the amount of reaming as well as distraction across the fracture site to provide the best fit for the nail.

Step 6 Insert the Nail

Be sure to maintain the reduction while advancing the nail across the fracture site. Reconfirm that traction has been reduced to avoid distraction at the fracture site.

Step 7 Insert Proximal and Distal Interlocks

Use the interlocking screws to secure the proper rotational alignment.

Step 8 Make Final Images and Close the Wound

Confirm the reduction and adequate fixation before closure.

Results

In our original study, a cohort of 246 femoral shaft fractures among 241 skeletally immature patients treated with trochanteric entry rigid intramedullary nailing was retrospectively reviewed.IndicationsContraindicationsPitfalls & Challenges.

Twenty-Year Experience with Rigid Intramedullary Nailing of Femoral Shaft Fractures in Skeletally Immature Patients

BACKGROUND

Debate exists over the safety of rigid intramedullary nailing of femoral shaft fractures in skeletally immature patients. The goal of this study was to describe functional outcomes and complication rates of rigid intramedullary nailing in pediatric patients.

METHODS

A retrospective review was performed of femoral shaft fractures in skeletally immature patients treated with trochanteric rigid intramedullary nailing from 1987 to 2009. Radiographs made at initial injury, immediately postoperatively, and at the latest follow-up were reviewed. Patients were administered the Nonarthritic Hip Score and a survey.

RESULTS

The study population of 241 patients with 246 fractures was primarily male (75%) with a mean age of 12.9 years (range, eight to seventeen years). The majority of fractures were closed (92%) and associated injuries were common (45%). The mean operative time was 119 minutes, and the mean estimated blood loss was 202 mL. The mean clinical follow-up time was 16.2 months (range, three to seventy-nine months), and there were ninety-three patients with a minimum two-year clinical and radiographic follow-up. An increase of articulotrochanteric distance of >5 mm was noted in 15.1% (fourteen of ninety-three patients) at a minimum two-year follow-up; however, clinically relevant growth disturbance was only observed in two patients (2.2%) with the development of asymptomatic coxa valga. There was no femoral head osteonecrosis. Among the 246 fractures, twenty-four complications (9.8%) occurred. At the time of the latest follow-up, 1.7% (four of 241 patients) reported pain. The average Nonarthritic Hip Score was 92.4 points (range, 51 to 100 points), and 100% of patients reported satisfaction with their treatment.

CONCLUSIONS

Rigid intramedullary nailing is an effective technique for treatment of femoral shaft fractures in pediatric patients with an acceptable rate of complications.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Biomechanical analyses of static and dynamic fixation techniques of retrograde interlocking femoral nailing using nonlinear finite element methods

Femoral shaft fractures can be treated using retrograde interlocking nailing systems; however, fracture nonunion still occurs. Dynamic fixation techniques, which remove either the proximal or distal locking screws, have been used to solve the problem of nonunion. In addition, a surgical rule for dynamic fixation techniques has been defined based on past clinical reports. However, the biomechanical performance of the retrograde interlocking nailing systems with either the traditional static fixation technique or the dynamic fixation techniques has not been investigated by using nonlinear numerical modeling. Three-dimensional nonlinear finite element models were developed, and the implant strength, fixation stability, and contact area of the fracture surfaces were evaluated. Three types of femoral shaft fractures (a proximal femoral shaft fracture, a middle femoral shaft fracture, and a distal femoral shaft fracture) fixed by three fixation techniques (insertion of all the locking screws, removal of the proximal locking screws, or removal of the distal locking screws) were analyzed. The results showed that the static fixation technique resulted in sufficient fixation stability and that the dynamic fixation techniques decreased the failure risk of the implant and produced a larger contact area of the fracture surfaces. The outcomes of the current study could assist orthopedic surgeons in comprehending the biomechanical performances of both static and dynamic fixation techniques. In addition, the surgeons could also select a fixation technique based on the specific patient situation using the numerical outcomes of this study.

Rigid intramedullary nail fixation of femoral fractures in adolescents: what evidence is available?

Background

Femoral fracture in adolescents is a significant injury. It is generally agreed that operative fixation is the treatment of choice, and rigid intramedullary nail fixation is a treatment option. However, numerous types of rigid nails to fix adolescent femoral fractures have been described. Hence, the aim of this paper was to collate and evaluate the available evidence for managing diaphyseal femoral fractures in adolescents using rigid intramedullary nails.

Materials and methods

A literature search was undertaken using the healthcare database website (http://www.library.nhs.uk/hdas). Medline, CINAHL, Embase, and the Cochrane Library databases were searched to identify prospective and retrospective studies of rigid intramedullary nail fixation in the adolescent population.

Results

The literature search returned 1,849 articles, among which 51 relevant articles were identified. Of these 51 articles, 23 duplicates were excluded, so a total of 28 articles were reviewed. First-generation nails had a high incidence of limb length discrepancy (Küntscher 5.8 %, Grosse–Kempf 9 %), whilst second-generation nails had a lower incidence (Russell–Taylor 1.7 %, AO 2.6 %). Avascular necrosis was noted with solid Ti nails (2.6 %), AO femoral nails (1.3 %) and Russell–Taylor nails (0.85 %). These complications have not been reported with the current generation of nails.

Conclusions

Rigid intramedullary nail fixation of femoral fractures in adolescents is a useful procedure with good clinical results. A multiplanar design and lateral trochanteric entry are key to a successful outcome of titanium alloy nail fixation.

Femoral fractures in children

PURPOSE OF REVIEW

Femoral fractures in children are the commonest children's fracture requiring hospitalization. They consume disproportionate amounts of healthcare resource. Advances in operative management have resulted in improved clinical and health economic outcomes.

RECENT FINDINGS

This article describes 21st-century management of femoral fractures concentrating on recent advances. There is a clear trend to increased operative management in all femoral fractures with improved outcomes in the proximal femur and shaft. Crucially, advances in the treatment of both have led to a reduction in the rate of avascular necrosis of the femoral head.

SUMMARY

Units treating paediatric fractures need access to specialist surgeons and equipment to treat the full range of femoral fractures and improve outcomes.

Biological fixation of fracture shaft femur in children

The aim of this work was to assess the results of biological fixation of fracture shaft femur in children with locked plates. Twenty-eight fractures in 26 children with closed fractures of the shaft of the femur were managed with biological plating using locked plates bridging the fracture site applied submuscularly through two small incisions above and below the fracture site. The mean age of the patients was 11.2 years; all patients had radiological union within a mean time of 11.9 weeks (8-14 weeks); the average follow-up was 31 months (14-40 months). No patient had frontal or sagittal plane deformity more than 10° or limb length discrepancy more than 1.5 cm. There was no infection, delayed union, nonunion or clinically evident malrotation. A significant positive correlation between the age and the time to healing (p = 0.03) was detected, whereas there was no significant correlation between time to healing and patient sex, fracture level, fracture type, mechanism of injury. Also there was no significant correlation between limb length discrepancy and patient age, sex, fracture level, fracture type, and mechanism of injury. Biological fixation of fractures of the femoral shaft in children with locked plates is a reliable method of fixation with excellent healing potential and fixation mechanics without complications.

Intramedullary nails for pediatric diaphyseal femur fractures in older, heavier children: early results

PURPOSE

A common treatment for pediatric femur fractures is intramedullary nail (IMN) insertion. Elastic stable intramedullary nails (ESINs) are often used for these procedures in heavier patients, but the potential for complications and malunion is greater. We describe here a rigid IMN specifically designed for adolescents, the adolescent lateral entry femoral nail (ALFN). The purpose of this study was to compare the recovery and complications for patients treated with ESINs to those treated with the ALFN.

METHODS

Our study design was a retrospective cohort study. We performed a review of medical records of 22 children ages 10-17 requiring surgical fixation of a femur fracture for a 2½-year period. Patients selected for the study had traumatic diaphyseal femur fractures and were treated with ESINs without end-caps or ALFNs. Our analyses evaluated injury, surgical, and outcome information for all patients.

RESULTS

Twenty-two patients were eligible for inclusion and were divided into two groups according to their treatment: the ESIN group with 7 patients and the ALFN group with 15 patients. We then performed a comparison of complications and recovery for these patients. The mean time to full weight-bearing was significantly less for the ALFN group (4.1 weeks; SD, 2.2), than the ESIN group (9.4 weeks; SD 3.9). There was no statistical difference in the incidence of major or minor complications.

CONCLUSIONS

Older, heavier pediatric patients treated for femur fracture with ALFNs had a shorter recovery time than similar patients treated with ESINs. However, the outcomes for both groups were satisfactory.

Treatment of femoral shaft fracture with an interlocking humeral nail in older children and adolescents

PURPOSE

Rigid interlocking nailing for femoral shaft fracture is ideal for use in adolescents in terms of stability of the fracture and convenience for the patient. However, numerous authors have reported that rigid interlocking nailing has some limitations in this age group due to the risk of complications. We evaluated the results of intramedullary nailing for femoral shaft fractures with an interlocking humeral nail in older children and adolescents.

MATERIALS AND METHODS

We retrospectively reviewed records of patients treated with an interlocking humeral nail. Radiographs were examined for proximal femoral change and evidence of osteonecrosis. Outcomes were assessed by major or minor complications that occurred after operative treatment.

RESULTS

Twenty-four femoral shaft fractures in 23 patients were enrolled. The mean age at the time of operation was 12 years and 8 months and the mean follow- up period was 21 months. Bony union was achieved in all patients without any complications related to the procedure such as infection, nonunion, malalignment and limb length discrepancy. All fractures were clinically and radiographically united within an average eight weeks. No patients developed avascular necrosis of the femoral head and coxa valga.

CONCLUSION

Intramedullary nailing through the greater trochanter using a rigid interlocking humeral nail is effective and safe for the treatment of femoral shaft fractures in older children and adolescents.

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.

Femoral fractures in adolescents: a comparison of four methods of fixation

BACKGROUND

The optimal management of femoral fractures in adolescents is controversial. This study was performed to compare the results and complications of four methods of fixation and to determine the factors related to those complications.

METHODS

We conducted a retrospective cohort study of 194 diaphyseal femoral fractures in 189 children and adolescents treated with elastic stable intramedullary nail fixation, external fixation, rigid intramedullary nail fixation, or plate fixation. After adjustment for age, weight, energy of the injury, polytrauma, fracture level and pattern, and extent of comminution, treatment outcomes were compared in terms of the length of the hospital stay, time to union, and complication rates, including loss of reduction requiring a reoperation, malunion, nonunion, refracture, infection, and the need for a reoperation other than routine hardware removal.

RESULTS

The mean age of the patients was 13.2 years, and their mean weight was 49.5 kg. There was a loss of reduction of two of 105 fractures treated with elastic nail fixation and ten of thirty-three treated with external fixation (p < 0.001). At the time of final follow-up, five patients (two treated with external fixation and one in each of the other groups) had >or=2.0 cm of shortening. Eight of the 104 patients (105 fractures) treated with elastic nail fixation underwent a reoperation (two each because of loss of reduction, refracture, the need for trimming or advancement of the nail, and delayed union or nonunion). Sixteen patients treated with external fixation required a reoperation (ten because of loss of reduction, one for replacement of a pin complicated by infection, one for débridement of the site of a deep infection, three because of refracture, and one for lengthening). One patient treated with a rigid intramedullary nail required débridement at the site of a deep infection, and one underwent removal of a prominent distal interlocking screw. One fracture treated with plate fixation required refixation following refractures. A multivariate analysis with adjustment for baseline differences showed external fixation to be associated with a 12.41-times (95% confidence interval = 2.26 to 68.31) greater risk of loss of reduction and/or malunion than elastic stable intramedullary nail fixation.

CONCLUSIONS

External fixation was associated with the highest rate of complications in our series of adolescents treated for a femoral fracture. Although the other three methods yielded comparable outcomes, we cannot currently recommend one method of fixation for all adolescents with a femoral fracture. The choice of fixation will remain influenced by surgeon preference based on expertise and experience, patient and fracture characteristics, and patient and family preferences.

Treatment of pediatric diaphyseal femur fractures

Methods of treating pediatric diaphyseal femur fractures are dictated by patient age, fracture characteristics, and family social situation. The recent trend has been away from nonsurgical treatment and toward surgical stabilization. The clinical practice guideline on pediatric diaphyseal femur fractures was undertaken to determine the best evidence regarding a number of different options for surgical stabilization. The recommendations address treatments that include Pavlik harness, spica casts, flexible intramedullary nailing, rigid trochanteric entry nailing, submuscular plating, and pain management. The guideline authors conclude that controversy and lack of conclusive evidence remain regarding the different treatment options for pediatric femur fractures and that the quality of scientific evidence could be improved for the revised guideline.

Biocompatibility of sol-gel-derived titania-silica coated intramedullary NiTi nails

We investigated bone response to sol-gel-derived titania-silica coated functional intramedullary NiTi nails that applied a continuous bending force. Nails 26 mm in length, either straight or with a radius of curvature of 28 or 15 mm, were implanted in the cooled martensite form from a proximal to distal direction into the medullary cavity of the right femur in 40 Sprague-Dawley rats. Body temperature restored the austenite form, causing the curved implants to generate a bending force on the bone. The femurs were examined after 24 weeks. Bone length measurements did not reveal any bowing or shortening of the bone in the experimental groups. The results from histomorphometry demonstrated that the stronger bending force, together with sol-gel surface treatment, resulted in more bone deposition around the implant and the formation of significantly less fibrous tissue. Straight intramedullary nails, even those with a titania-silica coating, were poorly attached when compared to the implants with a curved austenite structure.

Open intramedullary nailing in neglected femoral diaphyseal fractures

INTRODUCTION

Neglected femoral diaphyseal fractures are not uncommon in developing nations however there is a paucity of literature in this regard. Due to lack of effective traction, reduction or immobilisation these fractures are invariably associated with shortening and adjacent joint stiffness, presenting a challenging problem to the treating surgeon. The socioeconomic constraints in our society which result in patients seeking non-medical forms of treatment in the first place also warrant the need for an economically viable, simple effective form of treatment which can be carried out in a less advanced setup, gives reliable outcomes and allows early return to work.

METHODS

Eleven patients with neglected or late presenting femoral diaphyseal fractures were considered for the study. All patients underwent open intramedullary nailing, bone grafting and manipulation of the knee under anaesthesia. Iliac crest graft was harvested when local callus did not suffice. All patients received a supervised regimen of physiotherapy. Patients were followed up clinically and with plain radiographs at 6 weeks and 3 months to assess union and at monthly intervals thereafter.

RESULTS

The mean patient age was 28.8 years (15-48). The mean delay in presentation was 14 weeks (3-32 weeks). The mean shortening was 3.8 cm with four fractures showing signs of malunion. Five patients were given preoperative traction and bone resection was performed in only one patient. The mean hospital stay was 11 days (5-25 days). One patient was lost to follow up, of the remaining 10 patients all united at a mean of 11.9 weeks with 7 patients regaining full range of motion. The mean knee range of motion was 142.5 degrees . There were no wound related or neurological complications. One patient had a patellar tendon rupture which was repaired and another required dynamisation and bone marrow injection for delayed union.

CONCLUSION

We conclude that the treatment of neglected femoral diaphyseal fractures with open intramedullary nailing and bone grafting followed by manipulation of the knee with preoperative traction in selected cases is a satisfactory method of treatment showing reliable bony union however knee mobilisation should be undertaken with caution.

Intramedullary Kirschner wire (K-wire) fixation of femoral fracture in children

PURPOSE

The aim of this study was to evaluate the efficacy of standard intramedullary Kirschner wires (K-wires) for the treatment of femoral shaft fracture in children.

METHODS

We report the results of intramedullary K-wires nailing in 178 children with a mean age of 7.7 years (range, 4-14 years) from 2000 to 2005, retrospectively. A total of 184 diaphyseal femoral fractures were treated with both antegrade and retrograde nailing using the same principles of elastic stable intramedullary nailing (ESIN). The patients were followed for 12 months on average (range, 6-24 months).

RESULTS

No major complication (limb length discrepancy >15 mm, non-union, avascular necrosis, knee joint stiffness) occurred during the observation period. All fractures healed within 7.1 weeks on average (range, 5-12 weeks). Associated injuries were seen in 16.9% of the cases. All but seven fractures were reduced by closed manipulation. Early mobilization and weight bearing was allowed. Intramedullary K-wires were removed after an average of 4.8 months (range, 3-12 months) without any complications.

CONCLUSIONS

In children, intramedullary fixation by using standard K-wires provides effective treatment for the diaphyseal femoral fracture that has excellent clinical results. Each intramedullary K-wire costs US $5, which adds a cost effective advantage to this method of treatment.

Advances in the surgical management of pediatric femoral shaft fractures

PURPOSE OF REVIEW

To provide an update on surgical methods of pediatric femur fracture treatment.

RECENT FINDINGS

Multiple studies describe successful results with elastic nail stabilization of pediatric femur fractures. The indications and risk factors for complications are being more clearly defined. Trochanteric entry-locked intramedullary nailing and submuscular bridge plating have also recently been reported to produce excellent outcomes in a high percentage of patients. Older (>11 years) patients, heavier patients and patients with length-unstable fracture patterns may be best treated with locked nailing or plating.

SUMMARY

Pediatric femur fractures can be successfully treated by a number of methods. This review examines the recent literature to provide some guidelines for choosing amongst the options for surgical stabilization.