Femoral fractures in children

Closed reduction and intramedullary nails for acute completely displaced femoral diaphysis fracture in children aged 2-6

Background

The management of femoral fractures in children aged two to six years is still controversial. The purpose of this study was to assess the results of closed reduction and elastic stable intramedullary nail (ESIN) fixation in completely displaced fractures of the femoral diaphysis in children in this age group.

Methods

A retrospective review of all children with acute completely displaced fractures of the femoral diaphysis in children aged 2-6 years treated from 2013 to 2020 was performed. A total of 34 patients were treated who met the inclusion criteria: Group 1: 21 fractures (transverse and short oblique); Group 2: 13 fractures (long oblique and spiral) that underwent closed reduction and elastic stable intramedullary nail (ESIN) fixation. No differences existed between the 2 groups with respect to age, extremity, sex, time to treatment, mechanism of injury, or fracture displacement. Demographic characteristics and radiographs were reviewed, and the following parameters were documented: surgery time, time to union, return to activities, range of motion of knee joints, and complications. Major complications were defined as those with presumptive long-term side effects or those requiring a reoperation. No major complications were observed in the two groups. All included fractures were treated by a single senior paediatric surgeon. The mean follow-up period was 28.4 months (range 24-45 months). The level of significance was set at p < 0.05.

Results

Thirty-four children with acute completely displaced fractures of the femoral diaphysis were included: Group 1: 21 fractures; Group 2: 13 fractures. The patients included 15 girls (44.1%) and 19 boys (55.9%), with an average age of 4.4 years (range 2.8 to 6.5 years). The mean follow-up period was 28.4 months (range 24.2-45.0 months). The demographic characteristics did not differ between the two groups of patients. Overall, successful closed reduction and elastic stable intramedullary nail (ESIN) fixation could be achieved in all 34 patients. The mean surgical time was 40.4 and 43.0 min in Group 1 and Group 2, respectively (p = 0.857). Fluoroscopy time was not significantly different between the two groups (37.0 vs. 36.1 s, respectively; p = 0.247). Cosmetic results were described as good and satisfactory by all patients. There were no refractures and no incidences of nonunion or growth arrest in the proximal epiphysis. Only two patients suffered from a superficial infection, which was resolved after the pins were shortened and oral antibiotics were administered.

Conclusion

Closed reduction and elastic stable intramedullary nail (ESIN) fixation can be successfully used to treat completely displaced fractures of the femoral diaphysis in children aged two to six years. This technique is efficient and minimally invasive, and the results are satisfactory.

The incidence, trends, and costs of treatment of femoral shaft fractures among Finnish children aged 2-12 years between 1998 and 2016

Purpose

The purpose of this study was to determine the incidence and trends of both hip spica casting and elastic stable intramedullary nailing in children aged 2-12 years who sustained femoral diaphyseal fracture between 1998 and 2016 in Finland. We also evaluated the actual hospital costs of both treatment methods as well as calculating the length of hospital stay.

Methods

This study included all 2- to 12-year-old children with femoral diaphyseal fracture who were treated in Finland between 1998 and 2016. Data were collected from the National Hospital Discharge Register of Finland. Children were classified by age into five groups. The annual incidences per 100,000 persons were calculated using annual mid-year population census data obtained from Statistics Finland. Data on the annual actual daily hospital costs were collected from the Finnish Institute for Health and Welfare.

Results

In total, 1064 patients aged 2-12 years who had sustained femoral diaphyseal fracture were treated with elastic stable intramedullary nailing or hip spica casting between 1998 and 2016. In children aged 4-5 years, the incidence of elastic stable intramedullary nailing increased during the study period from 5.4 per 100,000 persons in 1998 to 8.1 per 100,000 persons in 2016.

Conclusions

The length of hospitalization in patients treated with elastic stable intramedullary nailing was shorter and, therefore, the total costs of hospital treatment were lower than in those children treated with hip spica cast.

Level of evidence

level III.

Submuscular Plating Versus Elastic Intramedullary Nailing in Children with Femoral Shaft Fracture; a systematic review and meta-analysis

Introduction

Elastic stable intramedullary nailing (ESIN) is currently the technique of choice for pediatric femoral fractures. Submuscular plating (SMP) allows reliable healing associated with an early range of motion. The following systematic review and meta-analysis was carried out to reveal the functional and surgical outcomes of SMP and ESIN for fixation of pediatric femoral fractures and to aid in the decision-making processes for those who perform these procedures.

Methods

An extensive systematic literature review was implemented from inception to 23 February 2022. All clinical studies included had patients that were younger than 18 years old with femoral shaft fractures that compared outcomes between SMP and ESIN. Studies including patients with pathological fractures, closed femoral physis, multiple fractures, or refractures were excluded.

Results

This meta-analysis included six articles encompassing 568 patients. Of them, 206 patients were treated with SMP, while 362 were subjected to ESIN procedure. There was significantly more blood loss among patients treated with SMP (MD -45.45; 95% -61.62, -29.27; p < 0.001). The risk of postoperative adverse surgical events was significantly higher among patients subjected to the ESIN (RR 2.97 19.5; 95% 1.27, 6.98; p = 0.01). The mean hospital stay was significantly shorter among patients subjected to ESIN (SMD -1.47; 95% -2.43, -0.51; p = 0.003). Patients subjected to SMP showed significantly more EFOs when comparing Flynn Scores (OR 0.24; 95% 0.09, 0.64; p = 0.004). There was no significant difference between SMP and ESIN regarding the mean operation time, limb length discrepancy, and mean time to union.

Conclusions

Children with femoral shaft fractures can be managed effectively and safely with SMP. There was a similar surgical outcome between SMP and ESIN, but SMP had more EFOs. While SMP was associated with a low risk of postoperative adverse surgical events, it was associated with a more significant blood loss and prolonged hospital stays.

Diaphyseal Femur Fractures in Children and Adolescents-Opportunities and Limitations of the ESIN Technique

Background: Elastic stable intramedullary nailing (ESIN) is the gold standard for non-overweight children aged 6−12 years. However, the complication rate using elastic stable intramedullary nailing is considerably high. Nevertheless, the question arises of whether the indication for elastic stable intramedullary nailing therapy can be extended and which factors must be taken into account when determining the indication. Methods: A retrospective chart review of patients <18 years admitted with diaphyseal femur fracture at a Level I Trauma Center in Germany between 2005 and 2017 was performed. In total, 118 patients were included. For the classification of femur fractures in children, the AO Pediatric Comprehensive Classification of Long-Bone Fractures (AO-PCCF) was applied. Results: Simple oblique fractures (32-D/5.1) occurred in most of the patients. Patients with simple oblique fractures were significantly younger compared to patients with simple transverse (32-D/4.1) or multifragmentary (32-D/5.2) fracture type according to the AO Pediatric Comprehensive Classification of Long-Bone Fractures. Most patients were treated with elastic stable intramedullary nailing (68 patients, 58%). Although children treated with elastic stable intramedullary nailing were older than those treated conservatively (25%, n = 29, mean age 1.5, median age 1.0), the children in the elastic stable intramedullary nailing group were comparatively young (range 1−12 years, mean age 5.4, median age 5). A total of 32 children below the age of 6 years were treated with elastic stable intramedullary nailing. Complications were more frequent in patients with overhead extension (50%) compared to conservative treatment with a spica cast (17%) or elastic stable intramedullary nailing (15%). Conclusions: Elastic stable intramedullary nailing therapy was associated with a low complication rate and was, therefore, a safe and frequently used treatment strategy in diaphyseal femur fractures with satisfactory results, even though the age groups were expanded in favor of younger patients.

Racial Disparities in Outcomes Following Open Treatment of Pediatric Femoral Shaft Fractures

Introduction Femoral shaft fractures are a common pediatric injury that can require non-operative or operative management. Several studies have shown that race impacts pain management and a number of emergency department visits in the pediatric femur fracture population. This study aimed to investigate any association between pediatric patient race and number of comorbidities, 30-day postoperative outcomes, and length of stay following open surgical treatment of femoral shaft fractures. Methods Pediatric patients who underwent open treatment of femoral shaft fracture were identified in the National Surgical Quality Improvement Program-Pediatric database from 2012-2019. Patients were categorized into two cohorts: White and underrepresented minority (URM). URM groups included Black or African American, Hispanic, Native American or Alaskan, and Native Hawaiian or Pacific Islander. Demographics, comorbidities, and postoperative complications were compared using bivariate and multivariable regression analyses. Results Of the 5,284 pediatric patients who underwent open treatment of femoral shaft fracture, 3,650 (69.1%) were White, and 1,634 (30.9%) were URM. Compared to White patients, URM patients were more likely to have a higher American Society of Anesthesiologists score (p=0.012), more likely to have pulmonary comorbidities (p=0.005), require preoperative blood transfusion (p=0.006), and have an increased risk of prolonged hospital stay (OR 2.36; p=0.007). Conclusion Pediatric URM patients undergoing open treatment of femoral shaft fractures have an increased risk of extended hospital stay postoperatively compared to White patients. As the racial and ethnic constitution of the pediatric population changes, understanding racial and ethnic health disparities will be crucial to providing equitable care to all patients.

The Bisaccia and Meccariello technique in pediatric femoral shaft fractures with intramedullary titanium nail osteosynthesis linked external-fixator (IOLE): validity and reliability

Background:

Over the last 20 years, the incidence of pediatric femoral shaft fractures was increased, due to changes in the children’s daily activities. The healing times are different according to the chosen treatment and to other factors such as age, type of fracture, the involvement of the soft tissues, and concomitance with other injuries. The Bisaccia and Meccariello technique (Intramedullary titanium nail Osteosynthesis Linked External-fixator -IOLE) was born to prevent rotationally and lengthening malunion or nonunion in the treatment of pediatric femoral shaft fractures.

Hypotheis:

The aim or the objective of this paper is to compare the IOLE with the two most used methods for the treatment of femoral fractures in children.

Methods:

From 2000 to 2016, 58 pediatric patients with femoral shaft fractures were surgically treated and enrolled in the study. The ranged age of the patients was between 3 and 15 years. Twenty-two patients were treated with endomedullary titanium nails (TEN), 22 with external axial or modular external fixators and 14 patients treated with IOLE technique. The IOLE technique, in brief, is the hybridization of titanium intramedullary nails with a modular external fixator. It is divided into three phases, the first revenue given the length of the femur with the external fixator; the second, the rotations are dominated by the elastic nails; and the third finally they are hybridized on the external fixator. Comparing the three groups, radiographic images were taken to assess fracture reduction and consolidation.

Results:

At the final follow-up, statistically significant differences in not weight-bearing times were found in favor of the IOLE group. There were no statistical differences between three groups in terms of significant rotation defects, angulation, growth, and/or nonunion.

Conclusions:

The Bisaccia- Meccariello technique (IOLE) showed to lead to healing the pediatric femoral shaft fracture of the femur but allows an early weight-bearing to these patients and normal life like that.

Management of Pediatric Femur Fracture Using 90-90 Traction

SUMMARY

This video discusses treatment of pediatric femur fractures using 90-90 traction, followed by delayed spica casting. This study details the treatment of a 2-year-old girl with a subtrochanteric femur fracture featuring a 4-cm acute shortening and severe malalignment. The patient was placed in 90-90 traction in the operative setting. When adequate callous was observed radiographically, the patient was treated with a spica cast in the hospital on day 16. She was noted to have obtained uneventful healing of the fracture with no functional deficits, as detailed during serial office visits.

The clinical features, management options and complications of paediatric femoral fractures

This article discusses the incidence, applied anatomy and classification of paediatric femoral fractures based on critical appraisal of the available evidence. The aim is to identify techniques that are relevant to contemporary practice whilst excluding the technical details of individual procedures that are beyond the scope of this review. Injuries of the proximal, diaphyseal and distal segments are considered individually as there are considerations that are specific to each anatomical site. Femoral neck fractures are rare injuries and require prompt anatomical reduction and stable fixation to minimise the potentially devastating consequences of avascular necrosis. Diaphyseal fractures are relatively common, and there is a spectrum of management options that depend on patient age and size. Distal femoral fractures often involve the physis, which contributes up to 70% of femoral length. Growth arrest is common consequence of fractures in this region, resulting in angular and length-related deformity. Long-term surveillance is recommended to identify deformity in evolution and provide an opportunity for early intervention. Deliberate injury should be considered in all fractures, particularly distal femoral physeal injuries and fractures in the non-walking child.

Pediatric Femoral Shaft Fracture: An Age-Based Treatment Algorithm

PURPOSE

Fractures of the femoral shaft in children are common. The rates of bone growth and remodeling in children vary according to their ages, which affect their respective management.

METHODS

This paper evaluates the incidence and patterns of pediatric femoral shaft fracture and the current concepts of treatments available.

RESULTS

The type of fracture-closed or open; stable or unstable-needs to be taken into account. Child abuse should be suspected in fractures sustained by infants. For younger children, non-surgical management is preferred, which include Pavlik harness (< 6 months old) and early spica casting (6 months to 6 years old). Older children (> 6 years old) usually benefit from surgical treatments as outcomes of non-surgical alternatives are worse and are associated with prolonged recovery times. These operative measures for older children that are 6-12 years old include elastic stable intramedullary nailing and submuscular plating. Factors to be considered when devising an appropriate intervention include body mass, location of injury, and nature of fracture. For adolescent and skeletally mature teenagers (> 12 years old), rigid antegrade entry intramedullary fixation is indicated. In the event of open fractures or polytrauma, external fixation should be considered as a temporary treatment method for initial fracture stabilization.

CONCLUSION

An age-based and evidence-based algorithm has been proposed to guide surgeons in the process of evaluating an appropriate treatment.

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.

Pediatric tibia and femur fractures in patients weighing more than 50 kg (110 lb): mini-review on current treatment options and outcome

The main objective of this paper is to review the current literature on treatment of tibial and femur fractures in children and adolescents guided by body weight in patients weighing 50 kg (110 lb) or more. A secondary aim of this mini-review was to determine, as per literature review, whether weight  > 50 kg (110 lb) is an identifiable factor associated with increased complication rate. A search of the PubMed/MEDLINE, EMBASE and Cochrane Database of Systematic Reviews databases from 1954 to September 2017 was performed to identify papers related to pediatric tibia and femur fractures in children weighing more than 50 kg (110 lb). Abstracts were screened, and relevant full-text articles were retrieved for further review. Reference sections of identified papers were also screened to identify further literature. All levels of evidence were included. Overall, seven full-text articles dealing with pediatric tibia or femur fractures in patients weighing more than 50 kg (110 lb), and one article reporting on both femur and tibia fractures in this patients' population, have been identified (n = 8 full-text article included). The articles reviewed a total of 679 children. In particular, 48/438 femur shaft fractures (mean weight: 51.7 kg or 113.9 lb) and 91/241 tibia fractures (mean weight: 53.3 kg or 117.5 lb) met the inclusion criteria. The overall rate of complications was 27.9%. In particular, the rate of complication was 51.7 and 29.6% in children with femur and tibia fracture weighing more than 50 kg (110 lb), respectively (p < 0.05). Elastic stable intramedullary nailing (ESIN) has become the treatment of choice for displaced tibia and femur shaft fractures in children between six and 12-15 years of age. Unstable fracture pattern, higher age and higher weight have been reported as potential risk factors associated with poor outcomes in children and adolescents treated with ESIN for displaced long bone fractures of the lower extremity, in particular femur shaft fractures. Despite these findings, data reporting exclusively on ESIN-treated long bone fractures in children weighing 50 kg (110 lb) or more remain scant.

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)

Comparison between external fixation and elastic stable intramedullary nailing for the treatment of femoral shaft fractures in children younger than 8 years of age

The main objective of this study was to compare external fixation (EF) with elastic stable intramedullary nailing (ESIN) for the treatment of femoral shaft fractures in children aged 8 or younger. Fifteen children with femoral shaft fractures treated by EF and 23 children with femoral shaft fractures treated by ESIN were retrospectively reviewed. All patients were pain free at the last follow-up, with good ranges of motion in the hip and knee. Partial and full weight bearing occurred sooner in patients treated with EF than with ESIN, although more polytrauma patients were present in the ESIN group. In conclusion, EF and ESIN can be considered as safe and effective methods for femoral shaft fracture treatment in children younger than 8 years of age.

Complications of elastic stable intramedullary nailing of femoral shaft fractures in children weighing fifty kilograms (one hundred and ten pounds) and more

AIM

The purpose of this study was to assess treatment outcomes in children weighing 50 kg (110 pounds) or more with displaced femur shaft fractures treated by elastic stable intramedullary nailing (ESIN) and to identify potential correlations between nail size/medullary canal diameter ratio and outcome.

METHODS

Twenty out of 117 consecutive children surgically treated by ESIN for displaced fractures of the femoral shaft with no associated neurovascular injury weighed 50 kg (110 pounds) or more. All patients underwent regular clinical and radiographic follow-up for at least one year after their index surgery.

RESULTS

The average patient age at the time of injury was 13.1 years (25th and 75th interquartile range [IQR] = 11.7-14.5). The mean follow-up was 27.4 months (IQR = 18.4-36.8). Overall, nine (45 %) adverse events were observed. The rate of complications was higher among children weighting 55 kg and over (67 %) than in children weighing less than 55 kg (35 %) and among children aged 13 years old or older (72 %) than among children younger than 13 years old (11 %).

DISCUSSION

Femoral shaft fractures in children and adolescents weighing 50 kg (110 pounds) and over and older than ten years of age have an increased rate of complications.

CONCLUSION

Heavier patients have a greater chance of complications. In particular, patients younger than 13 years old and weighing less than 55 kg can be safely managed with ESIN, but older and heavier patients should preferably be treated with rigid fixation systems due to a greater complication rate. However, further studies are needed to consolidate the conclusions.

The management of paediatric diaphyseal femoral fractures: a modern approach

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

Femoral shaft fractures in young children (<5 years of age): operative and non-operative treatments in clinical practice

BACKGROUND

Femoral shaft fractures comprise around 4 % of all long-bone fractures in childhood. There is controversy about the treatment of fractures in children below 5 years, between those preferring non-operative methods, such as casting or traction, and those supporting elastic stable intramedullary nailing (ESIN).

METHODS

This retrospective study evaluates the day-by-day treatment of femoral shaft fractures in children aged 6-60 months in four major paediatric surgery trauma centres in Germany from 1 January 2004 to 31 December 2011 by chart review. We analysed all patient-related data, causes of fracture, fracture type, treatment method and potential post-treatment complications.

RESULTS

We identified 225 patients (male to female 2:1) with femoral shaft fractures. Around 2/3 of these resulted from falls of less than 1 m or 1-3 m, the most frequent result (>40 %) being a long spiral fracture. All 19 children below 1 year of age were treated by casting or traction. Between the ages of 12 and 24 months (n = 56), different treatment concepts were preferred (1/5 ESIN, 2/5 traction and 2/5 spica casting). Between 24 and 36 months, operative and non-operative therapies were equally distributed. In children older than 36 months (n = 64), most fractures were treated by ESIN: six children by external fixation and 14 by other treatments like spica casting, plate osteosynthesis or a combination of methods. 42 changes of treatment were performed: traction to spica casting or secondary operative treatment and 21 complications occurred (nails left in place for too long, skin defects or wound infections).

CONCLUSIONS

Spica casting of femoral shaft fractures or, in some cases, traction is still the preferred treatment in the first and second years of life. In the third year, children are treated operatively as well as non-operatively, although now there is no current evidence of better short-term outcomes in operatively treated children. But elastic stable intramedullary nailing is the standard treatment for femoral shaft fractures in children older than 3 years of age.

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.