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

External fixator versus elastic stable intramedullary nail for treatment of metaphyseal-diaphyseal junction fractures of the pediatric distal femur: a case-control study

BACKGROUND

Several methods have been used for the treatment of pediatric distal femoral fractures, such as elastic stable intramedullary nail (ESIN), external fixator (EF) and plate osteosynthesis, but there has been no consensus about the optimal method. The purpose of this study was to compare the clinical outcome between EF and ESIN techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal femur.

METHODS

We retrospectively analyzed operatively treated MDJ fractures of pediatric distal femur between January 2015 and January 2022. Patient charts were reviewed for demographics, injury and data of radiography. All of the patients were divided into EF and ESIN groups according to the operation techniques. Malalignment was defined as more than 5 degrees of angular deformity in either plane. Clinical outcomes were measured by Flynn scoring system.

RESULTS

Thirty-eight patients were included in this study, among which, 23 were treated with EF, and 15 with ESIN. The mean follow-up time was 18 months (12-24 months). At the final follow-up, all of the fractures were healed. Although there were no statistical differences between the two groups in demographic data, length of stay, estimated blood loss (EBL), rate of open reduction, time to fracture healing and Flynn score, the EF was superior to ESIN in operative time, fluoroscopic exposure and time to partial weight-bearing. The EF group had a significantly higher rate of skin irritation, while the ESIN had a significantly higher rate of malalignment.

CONCLUSION

EF and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal femur. ESIN is associated with lower rates of skin irritation. However, EF technique has the advantages of shorter operative time, reduced fluoroscopic exposure, and shorter time to partial weight-bearing, as well as lower incidence of malalignment.

LEVEL OF EVIDENCE

Level III.

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.

Elastic Stable Intramedullary Nailing Versus Plate Internal Fixation for Pediatric Diaphyseal Femur Fractures: A Systematic Review and Meta-analysis

Background

Elastic stable intramedullary nailing (ESIN) and plates are currently the main internal fixation for treating Pediatric Diaphyseal Femur Fractures (PDFF), and the optimal choice of internal fixation is controversial. The purpose of this meta-analysis is to compare the surgical outcomes and complications of the two fixation methods.

Materials and Methods

MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published up to March, 2023, that compared ESIN and plate fixation techniques for treating PDFF. Pooled analysis identified differences in surgical outcomes between ESIN and plate, mainly regarding surgical outcomes and postoperative complications, such as time at surgery, fracture healing time, blood loss and related complications.

Results

We included 10 studies with 775 patients with PDFF in our review. Of these, 428 and 347 were treated with ESIN and Plate, respectively. In terms of postoperative complications, ESIN led to a shorter surgery time [MD = - 28.93, 95% CI (- 52.88 to - 4.98), P < 0.05], less blood loss [MD = - 66.94, 95% CI (- 87.79 to - 46.10), P < 0.001] and more fracture healing time [MD = 2.65, 95% CI (1.22-4.07), P < 0.001]. In terms of postoperative complications, ESIN led to fewer fections (RR = 0.77, 95% CI 0.37, 1.60, P = 0.48), fewer angulation deformities (RR = 0.80, 95% CI 0.35, 1.83, P = 0.60) and more prominent implants (RR = 3.36, 95% CI 1.88, 6.01, P < 0.001), more delayed unions (RR = 4.06, 95% CI 0.71, 23.06, P = 0.11).

Conclusions

ESIN and Plate have similar rates of complications besides a prominent implant rate, while ESIN has a shorter period of operation and less intraoperative bleeding. Although both options are suitable, the results of this study support the use of ESIN rather than plates in the treatment of PDFF in terms of complication rates. In clinical applications, surgeons should choose the appropriate treatment method according to the actual situation.

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.

Plate fixation versus flexible intramedullary nails for management of closed femoral shaft fractures in the pediatric population: A systematic review and meta-analysis of the adverse outcomes

Purpose

Fractures of the femoral diaphysis are associated with a risk of morbidity in children. Various fixation methods have been developed, but with only limited evidence to support their use. This systematic review assesses the evidence regarding clinical outcomes of closed femoral diaphyseal fractures in children treated with plate fixation or flexible intramedullary nails.

Methods

A PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis were conducted. MEDLINE, Embase, and Web of Science (WoS) databases were searched from inception to February 2023. Inclusion criteria included clinical studies reporting adverse outcomes following surgical treatment of pediatric closed femoral diaphyseal fractures using plate fixation and flexible intramedullary nails. The ROBINS-I and RoB 2 tools evaluated the risk of bias.

Results

Thirteen papers (2 prospective randomized controlled trials and 11 retrospective cohorts) reported 805 closed diaphyseal femoral fractures in 801 children (559 males, 242 females). There were 360 plate fixations and 445 flexible intramedullary nails. Two cases of osteomyelitis and one nonunion were reported. Meta-analysis showed that plate fixation had a lower risk of soft tissue infection (relative risk 0.26 (95% confidence interval 0.07-0.92)). There was no difference in the following outcomes: malunion (relative risk 0.68 (95% confidence interval 0.32-1.44)); unplanned reoperation (relative risk 0.59 (95% confidence interval 0.31-1.14)), and leg-length difference (relative risk 1.58 (95% confidence interval 0.66-3.77)). The risk of bias was high in all studies.

Conclusions

An analysis of 805 fractures with minimal differences in meta-analyses is considered high quality even when the quality of the evidence is low. The findings are limited by important flaws in the methodology in the published literature. Well-designed multicentre prospective studies using standardized core outcomes are required to advise treatment recommendations.

Level of evidence

III.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Efficacy of Single Titanium Elastic Nail in the Treatment of Child Femur Fractures

BACKGROUND

Femoral shaft fractures in childhood constitute an important part of emergency visits to orthopedic clinics. The aim of this study was to investigate the efficacy and reliability of a method in the treatment of simple fractures in the middle of the femoral diaphysis in patients with multiple injuries or in the treatment of cases with a medullary canal that is too narrow for two nails, with a single stretch nail thicker than half the diameter of the canal.

METHODS

Between July 2002 and November 2006, examinations were made of 11 femoral fractures in 11 patients who were admitted to the pediatric emergency department of Tepecik Training and Research Hospital with a diagnosis of femoral fracture and who were hospitalized and treated with a single flexible intramedullary titanium nail.

RESULTS

In the follow-up, no problem was found in terms of union and length difference in any of the cases, except for a 10º varus deformity present after surgery in one case.

CONCLUSIONS

Elastic intramedullary nailing is an effective method in the treatment of simple femoral fractures in children. A single elastic nail provides adequate stability following open reduction with minimal incision in patients whose short operating time must be kept short such as those with head trauma, thoracic trauma, or intra-abdominal pathology, or patients with a narrow medullary canal where two flexible nails cannot pass. We think that it is a feasible method because it causes minimal soft tissue damage.

Resource implications of managing paediatric femoral fractures in a major trauma centre: Analysis of 98 cases

INTRODUCTION

The management of paediatric femoral shaft fractures is expensive and is guided by age and fracture characteristics. The primary aim of this study was to perform a cost evaluation for managing paediatric femoral shaft fractures. The secondary aim of this study was to perform and compare costs of the different techniques of managing paediatric femoral shaft fractures.

METHODS

Ninety-eight femoral shaft fractures in children aged ≤16 were identified between 01/06/2014-30/06/2019. Retrospective data of clinical complications were obtained on infection, malunion and non-union. Data on additional intervention, reoperations for complications and routine removal of metal work were obtained. Costing analysis was performed by a bottom-up calculation, and gathering Patient Level Information and Costing System (PLICS) data.

RESULTS

There were 41 hip spica casting (HSC), 21 flexible intramedullary nailing (FIN), 14 submuscular plating (SMP), 19 rigid intramedullary nailing (RIN) and 3 external fixation (EF). Complications observed were HSC 3(7%); FIN 8(38%); SMP 2(14%); RIN 1(5%); EF 2(67%). The total costs for managing femoral shaft fractures were £8,955pp the costs for the different managements were; HSC £3,442pp; FIN £7,739pp; SMP £6,953pp; RIN £8,925pp; EF £19,116pp. The additional costs incurred for managing complications and routine removal of metal work for the internal fixation methods were: HSC 0.7%, FIN 23.7%, SMP 16.3%, RIN 10.9%, EF 28.1%.

CONCLUSION

The operative management of paediatric femoral shaft fractures is associated with a high cost burden and this study demonstrates how financial data can be used to influence clinical management strategy. RIN carry a high initial implant cost however when considering the additional costs, such as treating complications it remains comparable to other modes of fixation. Our cost analysis did not demonstrate a significant difference between FIN, SMP and RIN. Due to the clinical complications observed and associated additional costs, we have discontinued the routine use of FIN for femoral shaft fractures at our centre. We recognise other centres may have a different complication and cost profile for each technique, but recommend they evaluate their practice given the potential economic benefit it has on the service provider.

Suitability of skin traction combined with braces for treating femoral shaft fractures in 3-5 years old children

BACKGROUND

In children aged 3-5 years, femoral fractures are common and are frequently treated using flexible intramedullary nails (FIN) or spica casting. Recently, more surgeons have been relying on FIN surgery because of the high rate of complications associated with spica casts, such as skin irritation and re-adjustment surgery. We aimed to evaluate the effect of skin traction combined with braces in 3-5 years old children at our hospital.

METHODS

We retrospectively analyzed 125 children aged 3-5 years with femoral shaft fractures treated at our hospital between January 2010 and December 2020. We assigned 68 patients who underwent FIN surgery to Group A and 57 patients treated with skin traction and braces to Group B. Comparative analysis included the children's age, sex, side of the affected limb, cause of fracture, function of the knee joint, healing time of the fracture, duration of hospitalization, cost of hospitalization, and complications. The complications evaluated included joint dysfunction, pain, infection, pressure ulcers, angular deformities, limb length differences, re-fractures, nonunion fractures, and delayed union.

RESULTS

There were significant differences in and hospital costs (p = 0.001). Conversely, no statistically significant differences were observed in sex (p = 0.858), injury type (p = 0.804), age (p = 0.231), hospitalization time (p = 0.071), bone healing time (p = 0.212), and complications. Pressure ulcers, nonunion fractures, and delayed union did not occur in both groups.

CONCLUSION

Both methods had similar therapeutic effects and postoperative complications in children aged 3-5 years with femoral shaft fractures. Therefore, skin traction combined with braces is recommended for this population and for patients hospitalized in institutions where several beds are available, with a consequent possibility of prolonged hospitalization.

LEVEL OF EVIDENCE

IV.

Risk of complications following surgical fixation of femoral diaphyseal fractures in children aged 4 to 12 years: A systematic review and meta-analysis

INTRODUCTION

There is debate regarding the optimal surgical technique for fixing femoral diaphyseal fractures in children aged 4 to 12 years. The National Institute for Health and Care Excellence (NICE) and the American Academy of Orthopaedic Surgeons (AAOS) have issued relevant guidelines, however, there is limited evidence to support these. The aim of this study was to conduct a systematic review and meta-analysis to compare the complication rate following flexible intramedullary nailing (FIN), plate fixation and external fixation (EF) for traumatic femoral diaphyseal fractures in children aged 4 to 12.

METHODS

We searched MEDLINE, EMBASE and CENTRAL databases for interventional and observational studies. Two independent reviewers screened, assessed quality and extracted data from the identified studies. The primary outcome was the risk of any complication. Secondary outcomes assessed the risk of pre-specified individual complications.

RESULTS

Nine randomised controlled trials (RCTs) and 19 observational studies fulfilled the eligibility criteria. Within the RCTs, five analysed FIN (n = 161), two analysed plates (n = 51) and five analysed EF (n = 168). Within the observational studies, 13 analysed FIN (n = 610), seven analysed plates (n = 214) and six analysed EF (n = 153). The overall risk of complications was lower following plate fixation when compared to FIN fixation (RR 0.45, 95% CI 0.28 to 0.73, p = 0.001) in the observational studies. The overall risk of complications was higher following EF when compared to FIN fixation in both RCTs (RR 1.94, 95% CI 1.25 to 3.01, p = 0.003) and observational studies (RR 1.97, 95% CI 1.50 to 2.58, p<0.001). The overall risk of complications was higher following EF when compared to plate fixation in both RCTs (RR 7.42, 95% CI 1.84 to 29.98, p = 0.005) and observational studies (RR 4.39, 95% CI 2.64 to 7.30, p<0.001).

CONCLUSION

Although NICE and the AAOS recommend FIN for femoral diaphyseal fractures in children aged 4 to 12, this study reports a significantly decreased relative risk of complications when these injuries are managed with plates. The overall quality of evidence is low, highlighting the need for a rigorous prospective multicentre randomised trial at low risk of bias due to randomisation and outcome measurement to identify if any fixation technique is superior.

Treatment of closed femoral shaft fractures in children aged 2-10 years: a systematic review and meta-analysis

OBJECTIVE

To review current literature on treatment of closed femoral shaft fractures in children of 2-10 years old, with subgroup analysis of children aged 2-6 years, comparing intramedullary nailing (IMN) to conservative treatment modalities.

METHODS

We included clinical trials and observational studies that compared traction and subsequent casting (TSC), spica casting and IMN for treatment of femur shaft fractures in children of 2-10 years of age. Subgroup analysis of children aged 2-6 years was performed.

RESULTS

Compared to treatment with immediate spica casting, IMN led to significantly less coronal angulation (mean difference (MD): 2.03 degrees, confidence interval (CI) 1.15-2.90), less sagittal angulation (MD: 1.59 degrees, CI 0.82-2.35) and lower rates of LLD (Risk difference (RD): 0.07, CI 0.03-0.11). In terms of rehabilitation, IMN leaded to shorter time until walking with aids (MD: 31.53 days, CI 16.02-47.03), shorter time until independent ambulation (MD: 26.59 days, CI 22.07, 31.11) and shorter time until full weight bearing (MD: 27.05 days, CI 6.11, 47,99). Compared to TSC, IMN led to a lower rate of malunion (RD: 0.31, CI 0.05-0.56), shorter hospital stays (MD: 12.48 days, CI 11.57, 13.39), time until walking with aids (MD: 54.55, CI 40.05-69.04) and full weight bearing (MD: 27.05 days [6.11, 47,99]).

CONCLUSION

Although a lack of quality evidence, this systematic review showed a clear tendency to treatment with elastic intramedullary nails of femoral shaft fractures in children of 2-10 years of age.

LEVEL OF EVIDENCE

3.

Flexible Intramedullary Nailing of Femoral Shaft Fractures in Children Weighing ≥40 kg: A Systematic Review and Meta-analysis

BACKGROUND

Pediatric femur fractures are commonly treated with flexible intramedullary nails (FIN). However, there is controversy regarding the effect of patient weight on outcomes and complications. The purpose of this meta-analysis was to review the literature and describe implant choice, analyze complication, and reoperation rates; as well as the report clinical and radiographic outcomes of FIN in pediatric patients weighing ≥40 kg with femoral shaft fractures.

METHODS

A systematic review was performed of all retrospective and prospective studies focusing on the use of FIN in heavy children in Medline, Cochrane, and Web of Science databases. Data extraction was performed and summarized using descriptive statistics. Quality assessment was performed using the Newcastle-Ottawa Scale. Meta-analysis was performed for complications using pooled data from included studies.

RESULTS

The initial search strategy yielded 177 references, and after exclusions, 5 studies were included. The majority of studies were retrospective, and the most commonly used implants in heavier patients were titanium FIN and stainless steel Enders FIN. There were higher rates of radiographic nonunion and malunion, complications, and reoperations for refracture; and nonunion in heavier children treated with FIN. Meta-analysis performed on 4 applicable studies showed the overall complication rate was higher in the heavier patients compared with lighter patients (30.6% vs. 11.1%) with a relative risk of 1.20 [95% confidence interval (CI), 1.02-1.41]. Heavier patients also had higher rates of major complications (relative risk, 1.32; 95% CI, 1.03-1.69) but similar minor complications (relative risk, 1.13; 95% CI, 0.90-1.41).

CONCLUSIONS

Heavier children have worse radiographic outcomes and higher complication rates with the use of FIN for femoral shaft fractures. Additional research is needed to determine the effect of FIN material on clinical outcomes in heavier children, and the relationship between weight and other known risk factors for poor outcome in FIN, such as length stability.

LEVEL OF EVIDENCE

Level III-systematic review of level-III studies.

[Diaphyseal and metaphyseal femoral fractures in childhood]

Femoral fractures in childhood are rare and are usually the result of severe trauma. Conservative treatment (overhead extension, hip spica cast) can be used in children up to 3 years of age and beyond that elastic stable intramedullary nailing (ESIN) is the method of choice. The prognosis is very good if the surgical technique is adequate. In adolescents > 50 kg in body weight solid nails implanted via the greater trochanter are an alternative (adolescent lateral femoral nail, ALFN). External fixators and plate osteosynthesis are indicated in special situations. Femoral neck fractures are very seldom seen in this age group. Besides Kirschner (K)-wires and screw osteosynthesis a special pediatric hip plate is available in this situation. In the distal metaphysis mostly stable fractures occur in disabled children, which can usually be treated conservatively. In addition, pathological fractures occur in juvenile bone cysts and complex injuries in adolescents, which need stabilization by descending ESIN or with plates. At the distal growth plate relevant growth disturbances are possible.

Comparison of Open Reduction and Internal Fixation with Plate and Titanium Elastic Intramedullary Nail in Treating Pediatric Humeral Fracture

Objective

To investigate the therapeutic efficacy of titanium elastic intramedullary nail (TEN) and open reduction and internal fixation with plate (ORIF) in the treatment of humeral fracture in children.

Methods

A retrospective study was carried out in a total of 69 patients who were admitted to the hospital from January 2013 to December 2018. These patients, including 41 males and 28 females, were aged from 6 to 12 years old with a median of 8 years. These patients were diagnosed with humeral fracture and underwent the surgery of ORIF (n = 22) or TEN (n = 47). The intraoperative bleeding, operation time, length of stay (LOS), and fracture healing time were compared between the two groups. The therapeutic effect was assessed by the shoulder range of motion, the elbow range of motion, the UCLA shoulder function score, and the Mayo elbow performance score (MEPS) 6 months after the surgery.

Results

The intraoperative bleeding (97.20 ± 27.83 mL vs 185.60 ± 37.50 mL, P < 0.05), the operation time (53.70 ± 11.87 min vs 73.50 ± 13.33 min, P < 0.05), and the fracture healing time (9.30 ± 4.23 weeks vs 13.45 ± 3.67 weeks, P < 0.05) in the TEN group was significantly decreased than those in the ORIF group. There was no significant difference in the LOS between the two groups. The length of follow‐up is 3 and 6 months. The shoulder range of motion (110.88° ± 15.82° vs 98.37° ± 16.22° at 3 months and 162.88° ± 17.29° vs 117.65° ± 19.38° at 6 months, both P < 0.05), the elbow range of motion (105.23° ± 2.81° vs 87.12° ± 4.73° at 3 months and 137.47° ± 4.82° vs 109.67° ± 5.83° at 6 months, both P < 0.05), and the UCLA shoulder function score (28.58 ± 4.74 vs 21.64 ± 7.23 at 3 months and 33.05 ± 3.27 vs 25.78 ± 3.87 at 6 months, both P < 0.05), and the MEPS (80.76 ± 3.53 vs 65.33 ± 9.43 at 3 months and 97.48 ± 1.23 vs 88.22 ± 3.65 at 6 months, both P < 0.05) in the TEN group were greater than those in the ORIF group. In the TEN group, complications occurred in three of 47 cases (6.38%), including one case (2.13%) of bone nonunion and two cases (4.25%) of irritation response around the nail. In the ORIF group, complications occurred in four of 22 cases (18.18%), including one case (4.55%) of delayed healing, one case (4.55%) of deep infection, and two cases (9.08%) of radial nerve injury. The complication rate was not significantly different between the two groups.

Conclusion

TEN can be a good technique for the treatment of humeral fracture in children, with the advantages of less intraoperative bleeding, shorter operative time, quicker healing, and better recovery of shoulder range of motion and elbow range of motion.

Flexible nails have a significantly increased risk of complications compared with plating techniques when treating diaphyseal femoral fractures in children aged 5-12: A systematic review

BACKGROUND

One third of paediatric femoral fractures occur between the ages of 5 and 12. The American Academy of Orthopaedic Surgeons (AAOS) provide evidence-based guidance for treating such fractures that occur in children under 5 and over 12 but not for this age cohort. We aimed to synthesise the available evidence comparing flexible nailing versus plating techniques for diaphyseal femoral fractures in children between the ages of 5 and 12.

METHODOLOGY

A systematic review of interventional and observational studies was performed using MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, WHO Global Index Medicus and LILACS. The search strategy combined keywords for: children, diaphyseal femoral fractures, plates and nails. Two independent reviewers screened, selected, assessed quality and extracted data from identified studies. The primary outcome was overall complication rates. Secondary outcomes assessed rates of individual complications, and operative variables (e.g. operative time, blood loss).

RESULTS

Five studies fulfilled the eligibility criteria. No RCTs were identified. The studies included 308 femoral fractures in 306 patients: 174 fractures were treated with flexible nailing and 134 with plating. The post-operative complication rate was 27.0% (n = 47) after flexible nails and 12.7% (n = 17) after plating, relative risk 2.13 (95% CI 1.28, 3.53; p = 0.0035). The relative risk of malunion was 3.59 (95% CI 1.05, 12.25; p = 0.0409) with flexible nails and of prominent metalwork was 5.39 (95% CI 1.25, 23.31; p = 0.0241) with flexible nails.

CONCLUSIONS

Data on this topic for this age group is limited despite accounting for one third of paediatric femoral fractures. This review identified a significantly increased relative risk of all complications, and in particular with respect to malunion and prominent metalwork when fractures in this cohort are treated with flexible nails compared to plates. A multi-centre randomised trial to determine if either treatment is superior would be justified.

Length unstable femoral fractures: A misnomer?

BACKGROUND

Flexible intramedullary nailing (FIMN) is relatively contraindicated for pediatric length unstable femoral fractures.

AIM

To evaluate FIMN treatment outcomes for pediatric diaphyseal length unstable femoral fractures in patients aged 5 to 13 years.

METHODS

This retrospective study includes pediatric patients (age range 5-13 years) who received operative treatment for a diaphyseal femoral fracture at a single institution between 2013 and 2019. Length unstable femur fractures treated with FIMN were compared to treatment with other fixation methods [locked intramedullary nailing (IMN), submuscular plating (SMP), and external fixation] and to length stable fractures treated with FIMN. Exclusion criteria included patients who had an underlying predisposition for fractures (e.g., pathologic fractures or osteogenesis imperfecta), polytrauma necessitating intensive care unit care and/or extensive management of other injuries, incomplete records, or no follow-up visits. Patients who had a length stable femoral fracture treated with modalities other than FIMN were excluded as well.

RESULTS

Ninety-five fractures from ninety-two patients were included in the study and consists of three groups. These three groups are length unstable fractures treated with FIMN (n = 21), length stable fractures treated with FIMN (n = 45), and length unstable fractures treated with either locked IMN, SMP, or external fixator (n = 29). P values < 0.05 were considered statistically significant. Patient characteristic differences that were statistically significant between the groups, length unstable with FIMN and length unstable with locked IMN, SMP, or external fixator, were average age (7.4 years vs 9.3 years, respectively), estimated blood loss (29.2 mL vs 98 mL, respectively) and body mass (27.8 kg vs 35.1 kg, respectively). All other patient characteristic differences were statistically insignificant. Regarding complications, length unstable with FIMN had 9 total complications while length unstable with locked IMN, SMP, or external fixator had 10. Grouping these complications into minor or major, length unstable with locked IMN, SMP, or external fixator had 6 major complication while length unstable with FIMN had 0 major complications. This difference in major complications was statistically significant. Lastly, when comparing patient characteristics between the groups, length unstable with FIMN and length stable with FIMN, all characteristics were statistically similar except time to weight bearing (39 d vs 29 d respectively). When analyzing complication differences between these two groups (9 total complications, 0 major vs 20 total complications, 4 major), the complication rates were considered statistically similar.

CONCLUSION

FIMN is effective for length unstable fractures, having a low rate of complications. FIMN is a suitable option for length stable and length unstable femur fractures alike.

Expert Consensus for a Principle-based Classification for Treatment of Diaphyseal Pediatric Femur Fractures

INTRODUCTION

Recent studies demonstrate considerable deviation from the American Academy of Orthopaedic Surgeons (AAOS) evidence-based guidelines for the treatment of pediatric diaphyseal femur fractures (PDFFs). This study aimed to determine if expert-consensus can be reached on a principle-based classification to be applied broadly to a wide variety of PDFF scenarios and if outcomes correspond to adherence to the classification.

METHODS

A 2-stage study was performed. First, a survey of experts using a principle-based approach to PDFF. We conducted a survey of 17 thought-leaders (criteria≥20 y' experience+authors of the seminal pediatric femur fracture studies) who were asked to classify 15 cases of PDFF using the principle-based classification for agreement. Next, we conducted a retrospective review of 289 consecutive PDFF treated (2011-2015) at a level 1 pediatric trauma center. For each case, we compared the actual treatment and proposed "ideal" principle-based classification. We then compared clinical results and outcome data points including the length of stay, physician visits, and hospital charge data.

RESULTS

A substantial (κ=0.7) expert-agreement was noted for assigning treatment principles with near-perfect (κ=0.93) agreement on conservative versus surgical management. We obtained agreement on employing a flexible implant (κ=0.84) rigid fixation (κ=0.75) and damage control philosophy (κ=0.64). Suboptimal clinical results were noted in 43% of the undertreated patients (24/56), 18.8% of the adequately treated, and 14.3% of overtreated (P<0.01) patients. An increasing trend for the length of hospital stay and a number of clinic visits was noted as the treatment class increased (P<0.01). Charges were 4.2 times higher for an episode of operative versus nonoperative care (P<0.01). Rigid fixation (class 4) had significantly (P=0.01) higher total and material charges than flexible fixation (class 3).

DISCUSSION

The proposed classification has a substantial agreement among thought-leaders. Clinical results demonstrated significantly more suboptimal results in undertreated fractures, compared with ideally treated or more invasively treated fractures. More invasive treatments led to increased burden to families and the system in terms of length of stay and hospital charges.

LEVEL OF EVIDENCE

Level III.

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

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

Epidemiology of Femur Fractures in Children: A Descriptive Cross Sectional Study Based on a Rural Population of Nepal

Introduction:

Femur fracture in children is one of the most common lower limb fractures which require inpatient care. The aim of this study is to determine the epidemiology of femoral shaft fractures in children from a rural population of Karnali Nepal.

Methods:

Hospital records were retrospectively reviewed from May 2017 to April 2020 to identify all the children with femur fracture. Sociodemographic profile, mode of injury, fracture pattern and location, time of presentation, initial treatment by traditional bone setters, treatment method and duration of hospital stay were noted. Data analysis was done using Statistical Package for Social Sciences version 20.

Results:

Altogether 104 children were identified. The mean age was 5.55 years and boys predominated 65 (62.5%). Falls were the major mode of injury in 65 (62.4%) patients. Fractures were frequently noted between April 15 to August 15. There were four (3.8%) open fractures and concurrent fracture observed in eight (7.6%) patients. Ten (9.6%) children received prior treatment from traditional bonesetters. Treatment methods included hip spica 62 (59.6%), elastic intramedullary nailing 30 (28.8%) and plate fixation 12 (11.5%). The duration of hospital stay in the nailing and plate fixation group was 11.43 days and 18 days respectively

Conclusions:

Fracture was common in 2-6 years of age group in boys during summer. Fall from cliff, rooftop and ladder were the major preventable cause of fracture. Delayed presentation and prior treatment with traditional bone setters add special challenges to orthopedic surgeons working in rural teaching hospital.

Paediatric Long Bone Fractures Managed with Elastic Intramedullary Nails: A Retrospective Study of 30 Patients

Elastic intramedullary nailing or titanium elastic nail (TEN) is an alternative method for the treatment of various pediatric long bone fractures. Titanium nails are preferred over plaster cast and stainless steel nails for children older than six years. Our series included 30 paediatric long bone fractures who were managed with TEN. The mean age was 9.3 years and the mean follow-up period was 28 months. A mean time of 10 weeks was recorded for the union of all fractures. The occurrence of superficial infection in three cases healed with antibiotics and minor debridement. Limb length discrepancy was seen in three cases of femur fracture, which was functionally insignificant, but it may be a potential problem needing close follow-up until skeletal maturity is attained. An elastic intramedullary nail or TEN in long bone fractures in children is a safe and minimally invasive technique that achieves stable reduction, especially in long spiral fractures till union. We attained successful union and good results in all our 30 cases with long bone fractures in children. A few complications of hardware prominence were resolved with implant removal. Long-term studies with a comparison to casting techniques in paediatric long bone fractures are required.

Elastic Stable Titanium Flexible Intramedullary Nails Versus Plates in Treating Low Grade Comminuted Femur Shaft Fractures in Children

Objectives

To review the experience at our center with elastic stable titanium flexible intramedullary nails (ESIN) for pediatric femoral shaft unstable fractures.

Methods

From January 2015 to January 2017, 56 consecutive patients with femur shaft fractures were treated in our hospital. History and radiologic parameters were retrospectively reviewed. The inclusion criteria were: femur shaft fractures treated by ESIN or locking compressing plates (LCP); more than 2 years’ follow‐up care; and complete clinical information. A total of 51 patients were included according to the criteria: 16 girls and 35 boys. Ages at operation averaged 5.9 ± 2.8 years. Outcome: anteroposterior (AP) and lateral X‐ray radiographs were performed every 2 weeks before the fracture healing, every 3 months until 1 year, then once a year after the surgery. Clinical examinations were recorded for any clinical deformity, hardware prominence, pain, and infection. ESIN were applied in either a retrograde or an antegrade fashion for 29 patients. For 22 patients, LCP were implanted. For the remaining 5 cases, instruments other than ESIN and LCP were applied.

Results

The average follow‐up time was 29 months (range, 24–37 months). The average operation time was 78.2 min (range, 25–155 mins). The average blood loss in surgery was 69.6 mL (range, 3–700 mL). The average healing of fracture time was 2.2 month (range, 1–6 months). The average removal of implants time was 7.8 months (range, 3–20 months). The average expense for index operation was CNY 31 100 (CNY 17 500–142 200).

Comminution grades were strongly correlated with time to fracture union (P < 0.001, r = 0.53) and time to implant removal (P = 0.006, r = 0.38). For comminuted pattern, the operation time and blood loss during operation in LCP were significantly higher than those in ESIN (P = 0.037 and P = 0.006, respectively). Other clinical parameters were similar between the two groups. No clinically detectable LLD, rotational or angular deformity was found. All patients recovered full knee range of motion. In this series, 30 patients (59%) had complications; 26 minor complications (51%) did not require unplanned surgery, most of which were prominence of hardware; 4 patients (8%) had a major complication and underwent an unplanned surgery. Of these, 2 were refractures distal to primary fracture and 2 were intolerable prominence of ESIN.

Conclusions

Elastic stable intramedullary nails provide equivalent outcomes but decreased operative time and blood loss during surgery, and lower hospitalization cost in treating low‐grade comminuted femur shaft fracture compared with plating techniques. The results of this study support the use of ESIN over plates in low‐grade comminuted femur shaft fractures despite the fact that both options are indicated.

Locking plate fixation in pediatric femur fracture: evaluation of the outcomes in our experience

Background and Aim: Femoral shaft fracture is a common traumatic musculoskeletal injures in pediatric population. The treatment of diaphyseal femoral fractures depends on age patient and pattern fracture. We present our record about the use of locking plate fixation and their outcomes. Method: We conduct a retrospective analysis in 22 patients, surgically treated for 26 diaphyseal femur fracture between 2008 and 2013. The mean age was 13 years. All the patients underwent a clinical and radiological follow-up for two years. We recorded time to weight bearing, time to union, complication (malalignment, dysmetria, infection), time to resumption to sport, plate removal, parents’ satisfaction. Results: All the patients had a minimal clinical e radiological follow-up of 24 months. The average fracture healing time was of 7.4 weeks. All the patients had a full hip and knee range of movements. Fifteen patients developed minor malalignment (varo-valgus or procurvatum femur) without clinical effects. No cases of infections. The mean time to a full weight bearing was 12 weeks and the return to sportive activity was 24 weeks. Four patients required a plate and screws removal. The average result of parents’ satisfaction was 8/10. Conclusions: Locking plate fixation is to be considered a successful way of treatment for pediatric femur fractures, especially in patients older than 6 years, head-injured or in the treatment of polytrauma. The anatomic and functional outcomes are comparable to those of other fixation techniques for this kind of fracture. (www.actabiomedica.it)

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.