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

Management of Length Unstable Femur Fractures in Children by Flexible Intramedullary Nails: A Systematic Review

PURPOSE OF THE STUDY

Surgical options for paediatric femoral fractures include fl exible intramedullary nailing (FIN), plating, and external fi xators. Length unstable fractures are usually spiral, long oblique, or comminuted and are often associated with > 2 cm of shortening. The purpose of this study was to see whether FIN is effective for managing unstable femur fractures in children.

MATERIAL AND METHODS

An electronic literature search was performed up to 25 February 2022 in Cochrane Library, PubMed, and Embase databases using a combination of MeSH search terms and keywords related to the population (e.g., "child" AND "diaphyses" AND "femur"), and intervention (e.g., "nail" OR "ESIN"). The data extracted included the study details, Demographic data, surgical details, postoperative immobilization, complications, and outcome.

RESULTS

Eight studies with a total sample size of 369 patients were reviewed. The mean operative time, blood loss, and length of stay in the hospital were 67.62±12.32 minutes, 33.82±16.82 ml, and 4.9±1.27 days, respectively. The results were excellent in 61.92% of the patients, satisfactory in 32.61%, and poor in 5.43%. 4.54% of patients had major complications requiring reoperation and 32.46% of patients had minor complications. the most common complication was nail prominence seen in 26.30% of patients. Locked Ender's nail was associated with the least reoperation, malunion, and LLD rate compared to other types of FIN.

CONCLUSIONS

FIN along with a single walking spica cast is a good choice in all forms of paediatric femoral fracture patterns allowing proper alignment and rotation. Locked Ender's nail is safe and effective for managing unstable paediatric femur fracture.

KEY WORDS

pediatric femur fracture, length unstable, fl exible intramedullary nailing, submuscular plating, Flynn criterion.

Functional Outcome of Pediatric Subtrochanteric Fractures Treated With a Titanium Elastic Nailing System (TENS) Versus Plating

Introduction Uncertainty exists regarding the ideal course of therapy for subtrochanteric fractures in children of intermediate age. These fractures are challenging to treat, with scarce literature-based evidence to support a definitive implant. The ideal course of treatment should consider the patient's weight, age, femoral canal size, associated injuries, fracture stability, and surgeon's experience. A subtrochanteric femoral fracture in a child between the age of 5-12 is difficult to treat. For these patients, there is debate concerning the optimal internal fixation, hence this study was conducted to try and determine the superior mode of treatment for these fractures. The objective of this study is to compare functional outcomes of subtrochanteric fractures in the paediatric age group operated on with titanium elastic nail and plate fixation and the complications associated with both treatment modalities. Materials and methods This is a retrospective observational study of 40 cases that were admitted and operated on in the hospital of the current study from May 2007 to November 2021. Twenty patients underwent titanium elastic nailing system (TENS) nailing and the other 20 patients underwent plating for subtrochanteric fractures. The surgeries were conducted at our institute and patients were followed up at one-, three-, and six-month intervals. The final functional results were calculated with the help of the Flynn scoring system.  Results Out of 40 patients involved in the present study, 17 were female while 23 were male. Twenty patients received treatment with titanium elastic nails, and the remaining twenty received plating. The majority of the patients were males around 9.6 years of age on average in the plating group and 8.9 years in the nailing group. In comparison to 75% of participants in the plating group, 40% of patients who received nailing showed excellent results. Results were satisfactory for five patients who received titanium elastic nails and one who received plating. The only poor outcomes were noticed in six people (30%) in TENS and three people (15%) in the plating group who went through unplanned surgery for complications. In comparison to the plating group, the overall rate of complication was much greater in the TENS group. Conclusion We would like to conclude our study that, in accordance with Flynn's score, both elastic nailing and plating stabilization can produce positive functional outcomes. Both groups have a similar percentage of excellent and good results. We also conclude that the overall complication rate is slightly higher for patients treated with TENS when compared to plating for subtrochanteric fractures.

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.

Role of mini-invasive bridge plate in the complex femoral fracture in school going children: A prospective clinical study of 30 cases

Objective:

Pediatric femoral fracture including supracondylar and subtrochanteric fracture constitutes 1.6% of all paediatric fracture. Elastic nails remain the standard treatment of choice in a midshaft transverse femoral fracture in children weighing less than 45 kg. But in subtrochanteric and spiral femoral fracture, the failure rate of elastic nails are quite high. Hence, in accordance with AAOS guidelines, we treated complex femoral fracture in children with submuscular mini-invasive bridge plate because of its advantage of minimal incision, early union with proper alignment and lower failure.

Material and Methods:

We retrospectively reviewed 30 complex femur fracture in children treated with Submuscular bridge plate by mini-invasive approach. Patients were analysed according to their age, type of fracture, time of union in weeks, complication and results were evaluated with modified Flynn's criteria.

Result:

Out of 30 patients 28 were boys and 2 were females, with an average age of 11.5 years in which Spiral fracture (n = 12), subtrochanteric fracture (n = 9), Complex Shaft fracture (n = 10). All fracture united well on an average of 11 weeks. And 29 patients has excellent results and in 1 patient there is Acceptable result. The single complication was 3 mm limb lengthening but it didn't change gait of the patient.

Conclusion:

Mini invasive bridge plating is an easy and soft tissue preserving procedure for managing complex femoral fracture in children. It has shown promising results in achieving union without any major complication. We strongly recommend the SBP in a complex femoral fracture in children.

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.

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.

The optimal choice for length unstable femoral shaft fracture in school-aged children: A comparative study of elastic stable intramedullary nail and submuscular plate

The utilization of elastic stable intramedullary nail (ESIN) in length unstable femoral shaft fractures in children remains controversial, and the results in different studies vary a lot. This study aims to investigate the clinical outcomes of ESINs versus submuscular plate (SMP) in length unstable femoral shaft fractures.Patients aged 5 to 11 years old with length unstable femoral shaft fractures treated at our institute from January 2008 to January 2018 were included and categorized into ESIN and SMP group. The preoperative data and operative variables were collected from the hospital database, and postoperative data including complications were collected at follow-up visits.In all, 77 patients (8.1 ± 1.9 years old, male 45, female 32) in ESIN group and 45 patients (8.0 ± 2.2 years old, male 26, female 19) in SMP group were included in this study. Comparing operative variables, there was significantly less operative time, reduced estimated blood loss (EBL) and shortened hospital stay for ESINs as compared with SMP (P < .001). However, the fluoroscopy frequency was not significantly different between these 2 fixation methods (P = .42). As for elective removal surgery, there was significantly reduced operative time, EBL and shortened hospital stay for ESINs as compared with SMP (P < .001).Both ESIN and SMP are safe and effective choices for length unstable femoral shaft fractures in children aged 5 to 11 years. In ESIN, extra care is required to provide additional immobilization using spica cast or brace. Compared with SMP, ESIN is able to deliver comparable clinical outcomes with less EBL, operative time and shorter hospital stay.

Elastic nail fixation versus plate fixation of paediatric femoral fractures in school age patients - A retrospective observational study

INTRODUCTION

The management of paediatric femoral fractures continues to spark debate in published literature, with poor quality evidence guiding current guidelines on the optimum treatment in children. Many centres report excellent results for both elastic intramedullary nailing and plate fixation of diaphyseal femoral fractures. This study aimed to investigate the outcomes of femoral fractures treated with elastic nail fixation versus those treated with plate fixation in a tertiary children's trauma unit, and discuss the advantages and disadvantages of each technique.

MATERIALS AND METHODS

A retrospective review of all femoral fractures undergoing fixation at a level one paeditric trauma and tertiary referral unit, between 1st April 2009 and 30th April 2017, was performed.Clinical notes and radiographs were reviewed to determine patient demographics and injury, operative and hospital stay data. Radiological union, defined as bridging callus present on at least three out of four cortices on orthogonal radiographs, was determined at 12 weeks. Outcomes were determined using the Flynn Criteria. Patients were followed up for a minimum of 2 years. Data was statistically analysed, and a p value < 0.05 was considered significant.

RESULTS

There were a total of 28 patients- 14 in each treatment group. Patients undergoing elastic nail fixation were significantly older than plate fixation (9.7 ± 1.9 Vs 7.7 ± 1.8; p = 0.008). A male preponderance was noted (21/28), with no difference between groups (10 Vs 11; p = 1.00). Plate fixation demonstrated a tendency towards shorter length of stay (6.3 ± 2.1 Vs 7.8 ± 3.0; p = 0.134), earlier radiological union at 12 weeks (14 Vs 10; p = 0.098), lower postoperative analgesia requirements (0.82 ± 0.45 Vs 1.12 ± 0.97; p = 0.200), and better outcomes, as determined by the Flynn criteria.

CONCLUSIONS

In the authors opinion, plate fixation is a safe, effective alternative to elastic nail fixation with equivocal outcomes as determined by the Flynn Criteria. Plate fixation may offer advantages in shorter length of stay, reduced postoperative pain and earlier weightbearing. Further large scale, prospective research is required to determine whether these are borne out in practice.

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.

Pediatric Femoral Shaft Fractures: A Multicenter Review of the AAOS Clinical Practice Guidelines Before and After 2009

BACKGROUND

To determine if the AAOS clinical practice guidelines (CPG) for the treatment of pediatric femoral shaft fractures (2009) changed treatment, we analyzed pediatric femoral shaft fractures at 4 high-volume, geographically separated, level-1 pediatric trauma centers over a 10-year period (2004 to 2013).

METHODS

Consecutive series of pediatric femoral shaft fractures (ages, birth to 18 y) treated at the 4 centers were reviewed. Treatment methods were analyzed by age and treatment method for each center and in aggregate.

RESULTS

Of 2646 fractures, 1476 (55.8%) were treated nonoperatively and 1170 fractures operatively. Of the operative group, flexible intramedullary nails (IMN) were used for 568 patients (21.5%), locked intramedullary nails (LIMNs) for 309 (11.7%), and plating for 188 (7.1%). In total, 105 fractures were treated with external fixation or skeletal traction. Analysis before and after the CPG publication revealed a significant increase in the use of interlocked IMNs in patients younger than 11 years (0.5% before, 3.8% after; P<0.001). Over the same time period there was an increase in surgical management, regardless of technique, for patients younger than 5 years (6.4% before, 8.4% after; P=0.206). There were considerable differences in treatment among centers: 74% of fractures treated with plating were from a single center (center A), which also contributed 68% of patients younger than 5 years treated with plating; center B had the highest rate (41%) of flexible IMN in children younger than 5 years; center C had the highest rate (63%) of LIMN in children younger than 11 years; and center D treated the fewest patients outside the CPG guidelines.

CONCLUSIONS

Following publication of the AAOS CPG, there was a significant increase in the use of LIMNs in patients younger than 11 years old and a trend toward surgical treatment in patients younger than 5 years. The considerable variability among centers in treatment methods and adherence to the CPG highlights the need for further outcome studies to better define optimal treatment methods and perhaps update the AAOS CPG guidelines.

LEVEL OF EVIDENCE

Level III-therapeutic.

Retrograde Stainless Steel Flexible Nails Have Superior Resistance to Bending in Distal Third Femoral Shaft Fractures

BACKGROUND

It has been shown that retrograde titanium flexible intramedullary nails (Ti FIN) provide superior resistance to bending compared to antegrade Ti FIN in distal femur fractures. The purpose of this study was to compare resistance to torsional and bending forces of stainless steel (SS) FIN, with or without a locking screw, and Ti FIN in distal third femoral shaft fractures. We hypothesize that locked retrograde SS FIN will demonstrate greater resistance to both bending and torsional forces.

METHODS

Thirty adolescent synthetic femur models were used to simulate transverse distal femoral fractures at either 60 mm or 90 mm proximal to the distal femoral physis. The femurs were instrumented with antegrade Ti FIN, antegrade SS FIN, retrograde Ti FIN, retrograde SS FIN, or retrograde locked SS FIN. Three models for each construct at both osteotomy levels were tested. Models were analyzed to determine maximum resistance to bending and torsion.

RESULTS

In fractures 60 mm from the physis, retrograde SS FIN demonstrated statistically superior resistance to bending when compared with both antegrade and retrograde Ti FIN (P=0.001 and 0.008, respectively) and antegrade SS FIN (P=0.0001). Locked SS constructs showed a trend towards greater resistance to bending forces when compared with unlocked constructs (P>0.05). No significant difference was seen in resistance to bending when fractures were 90 mm proximal to the distal femoral physis between the five groups. No significant differences were observed in resistance to torsion in either the proximal or distal fracture models, regardless of construct type.

CONCLUSIONS

Retrograde SS FIN confer significantly greater resistance to bending forces for fractures 60 mm proximal to the distal femoral physis compared with Ti FIN or antegrade entry SS FIN. In fractures 90 mm from the physis, no differences were noted in our model. Our results support the use of retrograde SS nails in the pediatric patient with distal femoral shaft fractures.

LEVEL OF EVIDENCE

Level II-comparative biomechanical study.

Titanium elastic nailing versus locking compression plating in school-aged pediatric subtrochanteric femur fractures

The treatment of children between 5 and 12 years of age suffering from subtrochanteric femoral fracture is challenging. The optimal choice of internal fixation for these patients is controversial. The purpose of this study is to compare the outcomes and complications of titanium elastic nail and open reduction with plate fixation of subtrochanteric femur fractures in school-aged children.A total of 67 children aged 5 to 12 years with subtrochanteric femur fractures treated with titanium elastic nails or open plating were identified at our institution from January 2007 to December 2017. We retrospectively compared 39 children treated with titanium elastic nails with 28 children treated with open reduction and plate fixation. The data included age, sex, body weight, fracture pattern, operation time, blood loss, and length of hospitalization. The follow-up investigations included radiograph of pelvis, bilateral hip range of motion, bilateral femoral neck shaft angle, and length of lower extremity. The outcomes were classified according to Flynn classification as excellent, satisfactory, or poor. All the demographic characteristics were compared with statistical analyses.All 67 fractures united properly. No major postoperative complications were noted in both groups. No significant difference was found between the titanium elastic nail and open plating groups in terms of sex, fracture pattern, and length of hospitalization. We noted a significant difference between 2 groups in terms of age, weight, operation time, and blood loss. In total, we observed 24 excellent and 15 satisfactory results in the titanium elastic nail group, and 19 excellent results and 9 satisfactory results in the open plating group. There was no significant statistical difference between involved and uninvolved side of hip regarding range of motion and femoral neck shaft angle in both groups.Titanium elastic nail and pediatric hip plate fixation represent safe and effective methods in the treatment of subtrochanteric fractures in school-aged children. Titanium elastic nail internal fixation is a minimal invasive and simpler technique and suitable for young children of lower body weight. Open plate fixation is a more rigid fixation associated with a lower complication rate.

Pediatric Orthopedic Trauma: An Evidence-Based Approach

The management of pediatric fractures has evolved over the past several decades, and many injuries that were previously being managed nonoperatively are now being treated surgically. The American Academy of Orthopaedic Surgeons has developed clinical guidelines to help guide decision making and streamline patient care for certain injuries, but many topics remain controversial. This article analyzes the evidence regarding management of 5 of the most common and controversial injuries in pediatric orthopedics today.

Flexible Intramedullary Nails for Femur Fractures in Pediatric Patients Heavier Than 100 Pounds

BACKGROUND

Flexible intramedullary nailing (FIMN) of femoral shaft fractures in children >100 pounds remains controversial. The purpose of this study is to assess the relationship between patient weight and alignment at radiographic union following Ender's FIMN of pediatric femoral shaft fractures.

METHODS

An IRB approved, retrospective review of all patients who sustained a femoral shaft fracture treated by retrograde, stainless-steel Ender's FIMN was performed at a level 1 pediatric trauma center from 2005 to 2012. Preoperative radiographs were analyzed to determine fracture pattern, location, and isthmic canal diameter. Patient weight was measured on presentation to the emergency room. Radiographs at bony union were reviewed to measure shortening, coronal angulation, and sagittal angulation.

RESULTS

A total of 261 children underwent Ender's FIMN for femoral shaft fractures during the study period. There were 24 patients who weighed ≥100 lbs and 237 patients who weighed <100 lbs. There were no significant differences in sex (75% vs. 73% male), fracture stability (42.6% vs. 41.7% length unstable), or fracture patterns between the 2 groups. The ≥100 lbs group was significantly older (10.6 vs. 8.0 y, P<0.001). There were no significant differences in final coronal angulation (1.5 vs. 3.0 degrees), sagittal angulation (2.8 vs. 3.1 degrees), or shortening (3.4 vs. 3.5 mm) between the 2 groups. There were significantly more nail removals in the <100 lbs group (81.4% vs. 66.7%, P<0.01). Four percent of the population (10 patients) weighed ≥120 lbs and aside from age (11.4 vs. 8.1 y, P<0.01), there were no significant demographic or fracture pattern differences between this group and the remaining population. This heaviest group demonstrated no significant difference in shortening (3.3 vs. 3.5 mm), coronal angulation (0.8 vs. 3.0 degrees), or sagittal angulation (0.7 vs. 3.2 degrees) at radiographic union when compared with the lighter patients.

CONCLUSIONS

Stainless-steel Ender's FIMN is an effective treatment for pediatric femoral shaft fractures in patients ≥100 pounds with excellent radiographic outcomes and no increased risk for malunion.

LEVEL OF EVIDENCE

Therapeutic Level III.

[Effectiveness comparison of titanium elastic nail and locking compression plate fixation in treating femoral subtrochanteric fractures in older children]

Objective

To compare the effectiveness of titanium elastic nail (TEN) and locking compression plate fixation in treating femoral subtrochanteric fracture in older children.

Methods

Between April 2015 and September 2016, 35 older children (aged 7-13 years) with femoral subtrochanteric fractures were treated, the clinical data were retrospectively reviewed. TEN fixation was used in 19 cases (group A) and locking compression plate fixation in 16 cases (group B). There was no significant difference in age, gender, sides, fracture causes, type of fracture, and time from injury to operation between 2 groups ( P>0.05). The fluoroscopy times, operation time, intraoperative blood loss, fracture healing time were recorded and compared between 2 groups. The limb function was evaluated according to the Sanders scores and Flynn et al. outcome score.

Results

All the patients were followed up 6-24 months (mean, 11.46 months). The operation time, intraoperative blood loss, and fracture healing time of group A were significantly less than those of group B, but the fluoroscopy times of group A was significantly more than that of group B ( P<0.05). All the fractures were healed, no breakage of screw, infection of deep tissue, nerve injury, osteonecrosis of the femoral head, or other complication occurred. At last follow-up, according to the Sanders scores, the results were excellent in 14 cases, good in 4 cases, and fair in 1 case in group A with an excellent and good rate of 94.74%; the results were excellent in 12 cases, good in 3 cases, and fair in 1 case in group B with an excellent and good rate of 93.75%; showing no significant difference between 2 groups ( χ2=0.400, P=0.980). According to the Flynn et al. outcome score, the results were excellent in 13 cases, good in 5 cases, and fair in 1 case in group A with an excellent and good rate of 94.74%; the results were excellent in 11 cases, good in 3 cases, and fair in 2 cases in group B with an excellent and good rate of 87.50%; showing no significant difference between 2 groups ( χ2=0.748, P=0.688).

Conclusion

Both TEN and locking compression plate have satisfactory outcomes for treating pediatric femoral subtrochanteric fractures. TEN method has minimally trauma, security, and faster fracture healing when compared with locking compression plate.

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.

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.

Comparison of titanium elastic nails with traction and spica cast in treatment of children's femoral shaft fractures

Titanium Elastic Nails (TEN) are commonly used to stabilize femoral fractures in school-aged children, but there have been few studies assessing the risk of traditional traction and application of spica cast. The aim of this study was to compare of titanium elastic nails with traction and spica cast in treatment of children's femoral shaft fractures. A group of thirty children aged 6-12 years with one-sided femoral shaft fracture were randomly allocated either to traction with spica casting group or titanium elastic nails group and were followed up to 1 year. Factors such as age, sex, time needed for walking with aids, time needed for independent walking, time needed for callus formation, time absent from school, time spent in hospital, malunion, malalignment and wound complication were recorded and compared. Fifteen patients (10 boys, 5 girls) with a mean age of 8.33 +/- 1.63 years were treated by traction and spica casting. The other 15 (9 boys, 6 girls) with a mean age of 8.73 +/- 1.53 years underwent surgery using TEN. Mean absence time from school, length of hospital stay, time needed for walking with and without help and angular deviation (varus or valgus) were significantly lower in the group treated by TEN (p-value < 0.05). Time needed for callus formation was significantly lower in spica casting group (p-value < 0.001). No statistically significant difference was observed between the two groups regarding malunion wound complications and hospital charges. The results indicated that a child in whom a femoral fracture is treated with TEN achieves recovery milestones significantly faster than a child treated with traction and spica cast.

Comparison of titanium elastic nail and plate fixation of pediatric subtrochanteric femur fractures

BACKGROUND

Studies have demonstrated a higher risk of complications when children with fractures in the proximal third of the femur and length-unstable fractures are treated with titanium elastic nails. Alternative treatment methods include open plating and submuscular plating. We are not aware of any published studies that directly compare titanium elastic nail and plate fixation of pediatric subtrochanteric femur fractures. The purpose of the present study was to retrospectively compare the outcomes and complications of titanium elastic nail and plate fixation of subtrochanteric femur fractures in children and young adolescents.

METHODS

A total of 54 children aged 5 to 12 years with subtrochanteric femur fractures treated with titanium elastic nails or plating at 2 institutions between 2003 and 2010 were identified. We retrospectively compared 25 children treated with titanium elastic nails to 29 children treated with either open plating or submuscular plating. Similar to previous studies, a fracture that was located within 10% of the total femur length below the lesser trochanter was classified as subtrochanteric. Outcomes were classified as excellent, satisfactory, or poor. A major complication was defined as any complication that led to unplanned surgery. Minor complications were defined as complications that resolved with nonoperative treatment or did not require any treatment.

RESULTS

Outcome scores were significantly better in the plating group (P=0.03), but both groups demonstrated high rates of excellent and satisfactory results. The overall complication rate was significantly higher in the titanium elastic nails group (48%; 12 of 25) when compared with the plating group (14%; 4 of 29) (P=0.008). Patients in the titanium elastic nails group were advanced to full weightbearing significantly earlier (6.6 vs. 9.9 wk) (P=0.005). The major complication rate, length of hospitalization, and time to radiographic union were similar for the 2 groups.

CONCLUSIONS

Our results indicate that plate fixation of pediatric subtrochanteric femur fractures is associated with better outcome scores and a lower overall complication rate when compared with titanium elastic nails.

LEVEL OF EVIDENCE

Therapeutic Level III.

Submuscular bridge plating for complex pediatric femur fractures is reliable

BACKGROUND

Complex, high-energy pediatric femur diaphyseal fractures cannot be treated reliably by conventional methods: casting is not suitable for polytrauma and large children, external fixation is associated with a high rate of malalignment and refractures, elastic nails are unsuitable for unstable fractures and metaphyseal areas, and lateral trochanteric entry rigid nails cannot address proximal and distal fragments and need relatively large medullary canals. A few centers have reported that submuscular bridge plating (SBP) is associated with minimal complications, but these findings require confirmation.

QUESTIONS/PURPOSES

We asked whether SBP (1) reproducibly leads to union in unstable fractures with a low complication rate, (2) leads to reasonable alignment and leg length equality (3), is unaffected by age, weight, or location of fracture, and (4) is associated with no or minimal refracture after hardware removal.

METHODS

We retrospectively reviewed 60 fractures in 58 patients with pediatric diaphyseal femoral fractures treated with SBP from 1999 to 2011. The average age was 9 years. Forty (67%) of the fractures were unstable. Minimum followup was 2.4 months (average, 15.5 months; range, 2.4-50.6 months).

RESULTS

All fractures healed well and all patients returned to full activity. Two of the 58 patients (3%) had major complications leading to unplanned surgeries: one implant failure and one deep infection in an old open fracture. None of the patients developed clinically important malalignment or leg length discrepancy. Implant removal was performed in 49 patients without complications.

CONCLUSIONS

SBP provided reliable fixation and healing for complex pediatric femur fractures and can have a broader application in the orthopaedic community. SBP is our preferred method for unstable fractures or fractures of the proximal and distal shaft.

Acute complications associated with removal of flexible intramedullary femoral rods placed for pediatric femoral shaft fractures

BACKGROUND

The American Academy of Orthopaedic Surgeons position statement on the treatment of pediatric femoral shaft fractures could not comment on the safety of flexible intramedullary (IM) rod removal because of a lack of published evidence. This study reviews the acute complications of flexible IM rod removal from pediatric patients treated for femoral shaft fractures.

METHODS

A retrospective clinical and radiographic analysis at a single institution over a 5-year period. Demographic and radiographic parameters were analyzed to determine their influence on intraoperative and immediate postoperative complications.

RESULTS

One hundred sixty-three subjects (133 males, 30 females), mean age of 9.3±2.8 years (range, 2.7 to 14.8 y) and mean weight of 34.4±15.3 kg (range, 14.0 to 139.0 kg), underwent femoral flexible IM rod removal a mean 12.4±10.8 months (range, 2.4 to 63.8 mo) after placement with mean operative time of 51.1±22.3 minutes (range, 10 to 131 min). One hundred fifty-one subjects (92.6%) had stainless-steel Ender rods and the remaining nails were titanium. There were no significant demographic, intraoperative, or radiographic differences comparing subjects with Ender versus titanium rods. Indications for rod removal were pain at insertion site, family request, or surgeon's recommendation. There were 4 (2.5%) minor intraoperative difficulties, including the inability to remove 1 of 2 rods secondary to IM migration (n=1) and complete bone overgrowth at insertion site resulting in prolonged extraction time (n=3). Three of the 4 subjects had the rods placed >60 months before removal. Immediately postoperative (n=134), there were 4 (3.0%) complications, including superficial wound infection (n=3, 2.2%) and knee contracture (n=1, 0.8%). Subjects were released to full activities at a mean 4.7±1.8 weeks postoperatively with no known postoperative fractures.

CONCLUSIONS

The rate of intraoperative and immediate postoperative complications is low. Neither patient demographics, fracture characteristics, nor operative technique influenced the complication rate. Intraoperative difficulties may be minimized with removal of rods before signs of overgrowth.

LEVELS OF EVIDENCE

Level IV, intervention case series.

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.