Fractures of the femoral shaft in children: national epidemiology and treatment trends in England following activation of major trauma networks

The incidence of fractures in children under two years of age: a systematic review

BACKGROUND

Epidemiological research on fractures in children under the age of two is of great importance to help understand differences between accidental and abusive trauma.

OBJECTIVE

This systematic review aimed to evaluate studies reporting on the incidence of fractures in children under two years of age, excluding birth injuries. Secondary outcome measures included fracture location, mechanisms of injury and fracture characteristics.

METHODS

A systematic literature review (1946 to February 7th 2024), including prospective and retrospective cohort studies and cross-sectional cohort studies, was performed. Studies including children from other age groups were included if the actual measures for those aged 0-2 years could be extracted. We also included studies restricted to infants. Annual incidence rates of fractures were extracted and reported as the main result. Critical appraisal of was performed using the Appraisal tool for Cross-Sectional Studies.

RESULTS

Twelve moderate to good quality studies met eligibility criteria, of which seven were based on data from medical records and five were registry studies. Studies investigated different aspects of fractures, making comprehensive synthesis challenging. There was an overall annual fracture incidence rate of 5.3 to 9.5 per 1,000 children from 0-2 years of age; with commonest sites being the radius/ulna (25.2-40.0%), followed by tibia/fibula (17.3-27.6%) and the clavicle (14.6-14.8%) (location based on 3 studies with a total of 407 patients). In infants, the reported incidence ranged between 0.7 to 4.6 per 1,000 (based on 3 studies), with involvement of the clavicle in 22.2% and the distal humerus in 22.2% of cases (based on 1 study). Only a single metaphyseal lesion was reported (proximal humerus of an 11-month-old infant). Fracture mechanisms were detailed in four studies, with fall from chair, bed, table, own height or fall following indoor activities causing 50-60% of fractures.

CONCLUSIONS

There is a paucity of good quality data on fracture incidence in children under the age of two. Larger, prospective and unbiased studies would be helpful in determining normal pattern of injuries, so that differences from abusive trauma may be better understood.

Single-leg versus double-leg hip spica casts in the management of paediatric femoral shaft fractures? A systematic review and meta-analysis

Background

Paediatric femoral shaft fractures can be managed with single- or double-leg hip spica casting between ages six-months and six-years. The aim of this review was to determine if single-leg hip spicas reduce the impact on family life without compromising fracture stability.

Methods

The study was registered on PROSPERO (CRD42023454309). MEDLINE, Embase, Web of Science, Cochrane Library, and clinical trial registers were searched to May 2023 for level I-III evidence. Primary outcomes were impact on family life and fracture stability. Where appropriate, Meta-analysis was completed using RevMan v5.4. Risk of bias was assessed using RoB 2.0 (RCTs) and ROBINS-I (non-RCTs). Certainty of evidence was measured with GRADE.

Results

From 234 identified papers, four met the inclusion criteria (two RCTs; two non-RCTs). A total of 339 children were included (single-leg spica: 176; double-leg spica: 163). Three studies were 'high risk' and one study 'moderate risk' of bias. Impact on family life parameters were too heterogenous for pooled meta-analysis. Non-pooled data identified significantly more missed work days in the double-leg spica group and the 'Impact on Family' Scale significantly favoured single-leg spicas. For fracture stability, meta-analysis identified that (i) mal-union rates were significantly lower in single-leg spica: OR 0.08 (95 % CI 0.01 to 0.69; p = 0.02); (ii) MUA in theatre was not significantly different: OR 0.97 (95 % CI 0.19 to 4.86; p = 0.97); and (iii) wedge adjustment was not significantly different: OR 3.46 (95 % CI 0.48 to 24.92; p = 0.22). Certainty of evidence was assessed as 'very low'.

Conclusion

Single-leg hip spicas may be associated with reduced impact on family life without compromising fracture stability compared with double-leg hip spicas. However, the evidence is weak. Therefore, a propensity score matched observational study is required to understand if subgroups of patients (age, fracture pattern, mechanism of injury) would benefit from a single- or double-leg hip spica.

Paediatric femoral shaft fractures: an instructional review for the FRCS examination

This review presents the principal features of paediatric femoral shaft fractures including the contemporary management strategies and relevant supporting evidence. The article is an overview of information relevant to clinical practice, in addition to preparation for the FRCS (Orth) examination.

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.

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.

Development and validation of the MAnchester Needs Tool for Injured Children (MANTIC)

OBJECTIVE

To develop a measure of the needs injured children and their families' needs throughout recovery; The MAnchester Needs Tool for Injured Children (MANTIC).

DESIGN

Tool development, psychometric testing.

SETTING

Five children's major trauma centres in England.

PARTICIPANTS

Children aged 2 to 16 years with any type of moderate/severe injury(ies) treated in a major trauma centre within 12 months of injury, plus their parents.

METHODS

Stage 1a (Item generation): Interviews with injured children and their parents to generate draft items. Stage 1b (Co-production): Feedback about item clarity, relevance and appropriate response options was provided by parents and the patient and public involvement group. Stage 2 (Psychometric development): Completion of the prototype MANTIC by injured children and their parents with restructuring (as necessary) to establish construct validity. Concurrent validity was assessed by correlation with quality of life (EQ-5D-Y). MANTICs were repeated 2 weeks later to assess test-retest reliability.

RESULTS

Stages 1a,b: Interviews (13 injured children, 19 parents) generated 64 items with semantic differential four-point response scale (strongly disagree, disagree, agree, strongly agree). Stage 2: One hundred and forty-four participants completed MANTIC questionnaires (mean age 9.8 years, SD 3.8; 68.1% male). Item responses were strong requiring only minor changes to establish construct validity. Concurrent validity with quality of life was moderate (r = 0.55, P < 0.01) as was test-retest reliability (ICC = 0.46 and 0.59, P < 0.001). Uni-dimensionality was strong (Cronbach's α > 0.7).

CONCLUSION

The MANTIC is a feasible, acceptable, valid self-report measure of the needs of injured children and their families, freely available for clinical or research purposes.

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.

Paediatric Femoral Diaphyseal Fractures in a South Wales Tertiary Centre: An Account of Trend in Management and Complications Over 16 Years

Femoral shaft fractures in children have seen a number of interesting developments over the past 20 years. This is a retrospective cohort study looking into epidemiological and outcomes data of femoral shaft fractures in children treated at a tertiary centre in Wales from 2005-2021. Over a period of 16 years, there has been a significant increase in the number of rigid or elastic nailing and submuscular plating, coinciding with a dramatic reduction of external fixation for definitive treatment of diaphyseal femoral fractures. All patients above five years of age underwent operative fixation, with elastic or rigid intramedullary nailing the treatment of choice. Following multiple linear regression with 16 possible explanatory factors, this study found a statistically significant increase in time to union for open fractures, pre-operative translation, and operation time. Furthermore, there was a significant increase in post-operative leg length discrepancy for right versus left-sided fractures. Overall complication rates were 4% for minor and 8% for major complications. Complication rates were lowest for rigid intramedullary nailing and highest for external fixation. No cases of avascular necrosis were found for 27 rigid intramedullary nails inserted. Overall this study reports treatment choices and outcomes in keeping with current trends in management for paediatric femoral shaft fractures.

Developmental delay: is this pediatric patient population at risk for complications following open treatment of femoral shaft fracture?

PURPOSE

Femoral shaft fractures are common in the pediatric population, accounting for over 20% of inpatient pediatric fractures. Patients with developmental delays are a population group whose medical care and recovery come with a unique set of considerations and challenges. The purpose of this study was to evaluate the impact of developmental delay on outcomes following open treatment of femoral shaft fractures in the pediatric population.

METHODS

Pediatric patients undergoing open treatment of femoral shaft fracture from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Patients were divided into two groups: patients with developmental delay and patients without developmental delay. Patient demographics, comorbidities, and various postoperative outcomes were compared between the two groups using bivariate and multivariate analyses.

RESULTS

Of the 5896 pediatric patients who underwent open treatment of femoral shaft fracture, 5479 patients (92.9%) did not have developmental delay whereas 417 (7.1%) had developmental delay. Patients with developmental delay were more likely to have other medical comorbidities. Following adjustment on multivariable regression analysis to control for the baseline differences between the two groups, patients with developmental delay had an increased risk of readmission to the hospital (OR 4.762; p = 0.014).

CONCLUSION

Developmental delay in the pediatric population was found to be an independent risk factor for hospital readmission following open treatment of femoral shaft fractures. Taking these patients into special consideration when evaluating the optimal treatment plan can be beneficial to reduce the risks of readmission, which can decrease costs for both the patient and the hospital.

Incidence, characteristics, and treatments of traumatic open fractures in children and adolescents: A retrospective observational study

We aimed to investigate the incidence, characteristics, and treatments of open fractures in children and adolescents (≤18 years old). We retrospectively reviewed the records of 2418 children and adolescents who presented with traumatic fractures and were admitted to our university-affiliated hospitals, among which 206 patients (8.5%) presented with open fractures. The patients' clinical and radiographic records were reviewed, and the age, gender, cause of injury, injury season, injury week, associated injuries and complications were collected. This study enrolled 1789 males (74.0%) and 629 females (26.0%) with an average age of 11.2 ± 5.0 years. The patients were divided into an open fracture group (OF group, n = 206) and a group with no open fracture (No-OF group, n = 2212). There were 206 patients (8.5%) who presented with open fractures and the most common fracture sites were the tibia (31.1%, 64/206) and fibula (20.9%, 43/206). The patients in the OF group presented with higher frequency of emergency admission (P < 0.001), self-supporting medical insurance (P < 0.001), MVCs (P < 0.001), wounded by machine (P < 0.001), struck by object (P < 0.001), hurt/cut by others (P < 0.001), lower limb fractures (P < 0.001), multiple fractures (P = 0.010), associated injuries (P < 0.001) and wound infection (P = 0.003) then the patients in the No-OF group. The most common complication were wound infection (5.8%) and pneumonia (1.0%) in the OF group, wound infection (2.1%) and pressure sores (2.0%) in the No- OF group. Multivariate logistic regression analysis indicated that mechanical trauma (OR = 64.229, P < 0.001), being hurt/cut by others (OR = 26.757, P < 0.001), and being struck by an object (OR = 15.345, P < 0.001) were stronger risk factors for open fracture than were low falls; additionally, lower limb fractures (OR = 5.970, P < 0.001), upper limb fractures (OR = 5.865, P < 0.001) and multiple fractures (OR = 5.414, P < 0.001) were stronger risk factors than craniofacial fractures for open fractures. The frequency of surgical treatment for the patients with traumatic open fractures (87.9%, 181/206) was significantly higher than those without open fractures (72.2%, 1596/2212) (P < 0.001). The hospital stays and fees for surgical treatment for the patients with traumatic open fractures were significantly higher than those without open fractures (P < 0.001). Etiology (especially being injured by a machine or being hurt/cut by others) and the fracture site (including lower limb fractures and upper limb fractures) were independent risk factors for open fractures. Traumatic open fractures presented with higher surgical treatment rate, hospital stays and fees.

Results after skin traction for femur shaft fractures in children below the age of four years

Purpose

Nonsurgical management has been identified as the treatment of choice for femoral shaft fractures in children below four years of age. For various reasons, the surgical approach has become increasingly popular in recent years. The aim of this study is to report results after vertical skin traction and analyze the benefits of this technique as well as to point out advantages compared with surgery in this age group.

Methods

The authors performed a retrospective data analysis, including all patients with femoral shaft fractures below the age of four who were treated with vertical skin traction at our institution between January 2006 and December 2016.

Results

Skin traction for a femoral shaft fracture was performed for 36 patients (mean age 1.6 years; 1 day–3.5 years). The mean duration of traction was 18.5 days (14–30). Complications included soft tissue affections (n = 5), which all healed spontaneously. Consolidation was observed in all fractures. Initial axial deviations and shortening did not change during traction until consolidation (p > 0.05), and no relevant torsion deformity occurred (p = 0.01). Patients gained full weight-bearing within 12.3 days (7–40) following end of traction. At the final follow-up, after a mean of 29.3 months (12–192), leg-length discrepancy (mean 7.1 mm; 5–20) was found on radiograms in nine cases, and axial deviations (mean 7.7°; 5–25) were documented in seven cases. None of the patients had limitations in daily activities or sports.

Conclusion

Skin traction is a technically easy, safe, and non-invasive treatment modality for femoral shaft fractures in children below the age of four years. Strong results are obtained benefited from a high potential of growth-related correction, and in principle no anesthesia is needed. A prolonged hospitalization and socio-economic factors maintain the ongoing debate in comparison with the surgical approach.

Level of evidence

Level III, retrospective.

Epidemiology and associated injuries in paediatric diaphyseal femur fractures treated at a limited resource zonal referral hospital in northern Tanzania

Background

Diaphyseal femur fractures contribute up to 40% of paediatric orthopaedic admissions with the World Health Organisation data showing youth are particularly vulnerable and road traffic injuries are the leading cause of death for children and young adults. Different mechanisms results to these injuries and they vary with age and geographical location of the patient. Understanding the incidence, mechanism and pattern of these injuries allows planning for preventive measures and treatment to meet modern day patient demands, generation of appropriate and timely protocols with minimum social and economic burden to the patient and family.

Objectives and methods

A hospital based cross sectional study was conducted using the orthopaedic department patient registry among children aged under 18 years admitted from 2014—2018. Our research question was to determine the epidemiology of diaphyseal femur fractures and coexisting associated injuries among admitted paediatric orthopaedic patients. Patient files were reviewed from the medical records department and a data collecting sheet was used to record demographics and injury data. Odds ratios with 95% confidence intervals for associated injuries in paediatric diaphyseal femur fractures were estimated using multivariable logistic regression model.

Results

We found the prevalence of diaphyseal femur fracture among paediatric orthopaedic admissions was 18% with the majority 111 (68.5%) being males. The leading injury mechanism was a fall (57.4%) followed by road traffic injuries (35.8%) out of which 48.3% resulted from pedestrian vs motorcycle accidents. Traumatic brain injury (TBI) was the most common associated injuries accounting for 69% of these injuries with the majority 79% occurring in patients aged 6 years and older. With age specific analysis, children in 6–12 years and 13–18 years age groups, had 8 and 11 times higher odds for associated injuries (OR 8.25, 95% CI, 1.04—65.31) p = 0.046 and (OR 10.54, 95% CI, 1.26—88.31) p = 0.031 respectively compared to those younger ≤ 2 years. Road traffic related injuries had 17 times higher odds of associated injuries when compared to fall (OR 16.73, 95% CI, 6.28—44.57) p < 0.001. 112 (69.1%) of femur fractures were treated by non-operative method out of this 90 (55.6%) by traction with delayed Spica application. The overall mean duration of hospital stay was 18.5 ± 11 days.

Conclusion

Pedestrian vs motorcycle injuries was the leading specific cause of paediatric diaphyseal femur fractures with TBI being the common associated injury. Non-operative management was the most utilized treatment plan and contributed to ten times higher odds for a longer duration of hospital stay. Initiatives to insure children safety on roads should be strengthened in order to reduce/eliminate this burden. Application and practice of current evidence based clinical guidelines and recommendations is paramount for timely and appropriate treatment of these injuries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05320-x.

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.

Less malunion and shorter bone union time with titanium elastic nail treatment for isolated femoral shaft fractures in three- to six-year-old children

PURPOSE

Titanium elastic nail (TEN) is a good option for femoral shaft fractures in school-age children, whereas a spica cast is favored for younger patients. We aimed to compare these treatment modalities in a group of children aged three to six years.

METHODS

34 patients aged 3-6 years with an isolated closed femoral shaft fracture treated with TEN or one-leg spica cast immobilization were retrospectively assessed. Age, gender, weight, mechanism of injury, hospital stay time, bone union time, radiographic shortening, malunion, and complications were compared between the treatment groups.

RESULTS

16 (47.1%) patients who were treated with TEN (Group T) and 18 (52.9%) patients with spica casting (Group S) were included with a mean of 51 (24-94) months follow-up. The mean age was 4.98 years and statistically similar between both groups (mean, 5.2 vs. 4.8 years; p = 0.234). The patients in Group T were heavier (mean, 19.3 vs. 17.2 kg; p < 0.001) and were more likely to have a higher-energy mechanism of injury (p = 0.006). The mean late femoral shortening of Group S patient's was 6.5 ± 3.5 mm and significantly higher than Group T, which was 2.0 ± 2.9 (p = 0.050). However, effective late femoral shortening rates were not statistically different between groups (p = 0.347). Malunion was seen in six (33.3%) patients in Group S, whereas none of the patients in Group T had malunion at the last follow-up examination and were statistically different (p = 0.011).

CONCLUSION

Our study identified radiographic evidence favoring TEN over spica cast immobilization in treating preschool-age children with an isolated femoral shaft fracture in terms of malunion.

Prevalence of inflicted and neglectful femur shaft fractures in young children in national level I trauma centers

BACKGROUND

The prevalence of inflicted femur fractures in young children varies (1.5-35.2%), but these data are based on small retrospective studies with high heterogeneity. Age and mobility of the child seem to be indicators of inflicted trauma.

OBJECTIVE

This study describes other factors associated with inflicted and neglectful trauma that can be used to distinguish inflicted and neglectful from accidental femur fractures.

MATERIALS AND METHODS

This retrospective study included children (0-6 years) who presented with an isolated femur fracture at 1 of the 11 level I trauma centers in the Netherlands between January 2010 and January 2016. Outcomes were classified based on the conclusions of the Child Abuse and Neglect teams or the court. Cases in which conclusions were unavailable and there was no clear accidental cause were reviewed by an expert panel.

RESULTS

The study included 328 children; 295 (89.9%) cases were classified as accidental trauma. Inflicted trauma was found in 14 (4.3%), while 19 (5.8%) were cases of neglect. Indicators of inflicted trauma were age 0-5 months (29%, positive likelihood ratio [LR +] 8.35), 6-12 months (18%, LR + 5.98) and 18-23 months (14%, LR + 3.74). Indicators of neglect were age 6-11 months (18%, LR + 4.41) and age 18-23 months (8%, LR + 1.65). There was no difference in fracture morphology among groups.

CONCLUSION

It is unlikely that an isolated femur fracture in ambulatory children age &gt; 24 months is caused by inflicted trauma/neglect. Caution is advised in children younger than 24 months because that age is the main factor associated with inflicted trauma/neglect and inflicted femur fractures.

Therapy preference of 131 parents confronted with a pediatric femoral fracture

BACKGROUND

The management of femoral fractures in children between 3 and 5 years of age is still vividly debated. Therefore, we aimed to assess the basic attitude of parents if confronted with a hypothetical femoral fracture of their toddler.

MATERIALS AND METHODS

Parents of children aged between 12 and 36 months were asked for their preference after receiving detailed information on conservative and surgical treatment of femoral shaft fractures. Furthermore, we obtained information regarding the parents' gender, marital status, medical background, highest level of education and profession in a leading or non-leading position and if any of their children already had undergone any operations. The Freiburg Personality Inventory (FPI-R) questionnaire was used to assess parents' personality traits.

RESULTS

In total, 131 participants were included in this study. The vast majority (n = 116, 88.5%) preferred surgical treatment. The most frequently mentioned reasons for this decision were lack of acceptance, followed by faster reconvalescence, shorter hospital stay, less deformity or growth disorders and less stress on the child. The only reason stated against surgical treatment was the need of general anesthesia. A significantly higher rate of conservative procedures was noticed in self-employed participants and stress was found to significantly influence the treatment decision of the parents toward conservative treatment.

CONCLUSION

The majority of parents confronted with a hypothetical femoral fracture of their child questioned in this study opted for a surgical approach with elastic stable intramedullary nailing (ESIN). This corresponds with trends toward surgery in these cases in major trauma centers in Europe.

Incidence, pattern and mechanisms of injuries and fractures in children under two years of age

Background

Fractures in children under 2 years of age are rare, and little has been published on their mechanisms. We aimed at examining the incidence, mechanisms, pattern and fracture characteristics in a large, population-based cohort of otherwise healthy children.

Methods

This retrospective, cross-sectional study includes all children aged 0–2 years, attending the Accident and Emergency department in Bergen between 2010 and 2015, due to an injury warranting radiography. Clinical data was categorized from the medical notes, and all radiographs were reviewed by an experienced paediatric radiologist.

Results

In total 408 children (212 male), 3–23 months of age (mean 17.7 months), were included. 149 (77 male) children had a total of 162 fractures, yielding an annual incidence of 5.4 per 1000, varying from 0.7 per 1000 for those under 12 months of age, increasing tenfold to 7.3 per 1000 for children aged 12–24 months of age. More than half of the fractures (53.1%) were seen in children aged 18–23 months, while none was found in those under 7 months of age. The youngest age group had mostly femur and tibia fractures, the oldest mostly forearm fractures (n = 55, 33.9%), followed by tibia fractures (21.6%) and fractures to the clavicle (14.8%). The reported mechanisms for the 162 fractures were fall from a chair/bed/table (41.4%), fall from own height (18.5%) or crush injury (15.4%). In 8 of 162 (4.9%) fractures, the history was clearly inconsistent and suspicious of non-accidental injury (NAI).

Conclusion

Injuries and fractures in young children in general, and non-ambulant children in particular, are rare and should be thoroughly assessed for NAI. Level of evidence: Retrospective, population based cross-sectional study. Level 3.

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.

The epidemiology of infant shaft fractures of femur or humerus by incidence, birth, accidents, and other causes

Background

The purpose of this population-based registry study was to analyze both birth-related femur and humerus shaft fractures and diagnosed later in infancy, as regards incidence, perinatal characteristics, other diagnoses, and reported accidents.

Methods

Children born in 1997–2014, diagnosed with a femur or humerus shaft fracture before age 1 year, were identified in the Swedish Health Registries. Rate of birth fractures were estimated by combining femur and humerus shaft fractures coded as birth-related with femur and humerus shaft fractures diagnosed during day 1–7 without registered trauma or abuse. Incidence was computed by comparing infants with femur or humerus shaft fractures to the total at-risk population.

Results

The incidence for birth-related femur shaft fractures was 0.024 per 1000 children (n = 45) and that for birth-related humerus shaft fractures was 0.101 per 1000 children (n = 188). The incidence was 0.154 per 1000 children for later femur shaft fractures (n = 287) and 0.073 per 1000 children for later humerus shaft fractures (n = 142). Birth-related femur shaft fracture was associated with shoulder dystocia, cesarean, multiple birth, breech, preterm, and small-for-gestational age, while humerus shaft fracture was associated with maternal obesity, dystocic labor, shoulder dystocia, vacuum-assisted delivery, male sex, multiple birth, breech, preterm, large-for-gestational age, birth weight > 4000 g, and injury of brachial plexus. A bone fragility diagnosis was recorded in 5% of those with birth-related or later femur shaft fractures. Among infants with birth-related humerus shaft fractures, 1% had a bone fragility diagnosis; the figure for later fractures was 6%. Maltreatment diagnosis was associated with later fractures of both types, especially among those aged < 6 months, where approximately 20% (femur) and 14% (humerus) of cases, respectively, were associated with abuse. Fall accidents were reported in 73 and 56% among those with later femur and humerus shaft fractures, respectively.

Conclusion

This study provides data on epidemiology, birth, parental characteristics, and reported accidents in relation to femur and humerus shaft fractures during infancy. Few children had a bone fragility diagnosis. Fall accidents were the main contributor to femur or humerus shaft fracture during infancy; however, the proportion of fractures attributed to maltreatment was high in children under 6 months.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03856-4.

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.

Lower limb paediatric trauma with bone and soft tissue loss: Ortho-plastic management and outcome in a major trauma centre

AIM

We examined the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss.

METHOD

Patients were identified from our prospective trauma database (2013-2018). Inclusion criteria were age (<18 years) and open lower-limb trauma. We assessed severity of soft tissue and/or bone loss, fracture complexity, surgical techniques and time to surgery. Paediatric quality of life and psychological trauma impact scores (HRQOL and CRIES), Ganga Hospital Injury Severity score (GHISS), union and complication rates were measured.

RESULTS

We identified 32 patients aged between 4 and 17 years. Twenty-nine patients had open tibia fractures including 14 patients with bone loss, one patient had an open femur fracture, one patient an open talus fracture and one an open ankle fracture with dorsal degloving. Thirty injuries were classified intra-operatively as Gustilo IIIB (or equivalent) and two injuries as Gustilo IIIC. In 10 patients primary skin closure was achieved by acute shortening following segmental bone loss. Twenty-two patients required soft tissue coverage: 17 free vascularised flaps, two fascio-cutaneous flaps and three split skin grafts were used. Two patients required vascular repair. Soft tissue coverage was achieved within 72 hours in 26 patients (81%) and within a week in 30 patients (94%). The surgical techniques applied were: circular fine wire frame (19), monolateral external fixator (4) and open reduction internal fixation (8). Median follow up time was 18 (7-65) months. Paediatric quality of life scores were available in 30 patients (91%) with a median total score of 77.2 out of 100. The psychological trauma impact scores showed one in three patients was at risk of developing post-traumatic stress symptoms (PTSD). The GHISS scores ranged from 6-13. All fractures went on to unite over a median time of 3.8 (2-10) months. Three patients (9%) had major complications; two flap failures requiring revision, one femur non-union requiring revision fixation.

CONCLUSION

Limb salvage and timely fracture union is possible in children with complex lower limb trauma. Early intervention providing adequate debridement, skeletal stabilisation and early soft-tissue cover including the option of free microvascular reconstruction in small children when required, delivers acceptable outcomes. A multidisciplinary team approach including clinical psychologists to address the psychological impact of trauma provides optimal holistic care for these children and adolescents. Therefore, treatment for these patients should only be performed in paediatric major trauma centres.

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.

Epidemiological evaluation of traumatic lower limb fractures in children: Variation with age, gender, time, and etiology

To investigate the age, gender, time, and etiology differences of traumatic lower limb fractures (TLLFs) in a population of children (≤18 years old), we retrospectively reviewed 936 children who had TLLFs and who came to our university-affiliated hospitals from 2001 to 2010. This study enrolled 657 males (70.2%) and 279 females (29.8%) aged (11.6 ± 4.9) years old. The most common etiologies and fracture sites were motor vehicle collisions (MVCs, 440, 47.0%) and tibias (376, 40.2%). A total of 126 (13.5%) patients suffered neurological deficits (NDs), 127 (13.6%) patients sustained associated injuries (ASOIs), and 78 (8.3%) patients sustained complications. During all periods the occurrence increased with increasing age group and a male preponderance was observed in all age groups. With increasing age, the proportion of injuries due to different etiologies increased and the proportion of femur fracture decreased from 65.2% to 34.5%. With increasing year of admission, the proportion of injuries due to MVCs decreased. The most common fracture sites were tibias in MVCs, femurs in low fall, high fall, and struck by object, feet in sprain. Male patients presented with significantly higher proportions of injuries due to struck by object and sprain, significantly lower proportions of pelvis fracture than the female patients. MVCs and tibias were the most common etiologies and fracture sites. Prevention and treatment should be taken according to the pattern of TLLFs which have specific annual, gender, and age characteristics.