Social and economic benefits of flexible intramedullary nails in the treatment of pediatric femoral shaft fractures

Rust score-An adequate rehabilitation guide for diaphyseal femur fractures managed by TENS

INTRODUCTION

The optimal mode of treatment among the wide variety of surgical and nonsurgical treatment options for children between 5 and 15 years of age continues to be controversial. Elastic stable intramedullary nailing of long bone fractures in the skeletally immature has gained widespread popularity because of its clinical effectiveness and low risk of complications.

METHODS AND METHODOLOGY

From Jan 2015 to August 2016, 35 patients including 37 limbs with diaphyseal fractures of the femur in the age group 5-15 years were managed by Titanium Elastic nailing and their clinico-radiological and functional outcome was assessed at 1 year post operatively as per the Flynn's criteria. RUST score was used as a guide for post-operative rehabilitation.

RESULTS

37 patients were managed by TENS nailing including 28 males and 9 females. The outcome in proximal, middle or distal fractures of the shaft were found to be similar and the difference was statistically insignificant. Similarly, the difference in the outcomes as per fracture patterns was also found to be statistically insignificant. Partial weight bearing was allowed after a score of 6 was achieved and full weight bearing after a score of 8.

CONCLUSION

As per the Flynn's criteria, 75% of the patients (28 out of 37) were found to have an excellent outcome while 7 had a satisfactory outcome and two had a poor outcome. RUST score can be used as an effective guide for post op rehabilitation.

ediatric femoral shaft fractures treated by flexible intramedullary nailing

BACKGROUND

Nowadays pediatric femoral fractures are more commonly managed with operative treatment rather than conservative treatment because of more rapid recovery and avoidance of prolonged immobilization. Children between the ages of 5-13 years are treated either by traction plus hip spica and flexible/elastic stable retrograde intramedullary nail, or external fixators in the case of open fractures. The aim of this study is to evaluate the outcome of pediatric femoral shaft fractures treated by stainless steel flexible intramedullary nail in children between 5 and 13 years of age.

METHODS

There were 32 cases of femoral shaft fractures which were all fixed with stainless steel flexible intramedullary nail under fluoroscopy. Long leg cast was applied at the time of fixation. Partial weight bearing was started 2 weeks after surgery. Patients were evaluated in follow-up study to observe the alignment of fracture, infection, delayed union, nonunion, limb length discrepancy, motion of knee joint, and time to unite the fracture.

RESULTS

We were able to follow up 28 out of 32 patients. The patients were 8.14 years of age on average. The mean hospital stay after operation was 4 days and fracture union time was 9.57 weeks. There were 3 cases of varus angulation, 2 cases of anterior angulation, and 4 cases of limb lengthening.

CONCLUSION

Patients aged between 5 and 13 years treated with flexible intramedullary nail for closed femoral shaft fracture have rapid union and recovery, short rehabilitation period, less immobilization and psychological impact, and cost-effective.

Treatment outcomes after insufficiency femoral diaphyseal fractures in nonambulatory children

We retrospectively reviewed the treatment and outcomes of diaphyseal femur fractures in a cohort of nonambulatory children. There were 30 patients (38 fractures) reviewed [average age of 10.1 years (range: 1.8-17.8)]. Fractures were treated with locked plate/screw fixation (n=18), with a complication rate of 24% (9/38). Patients with elastic stable intramedullary nailing experienced the highest complication rate (5/7, 71%) compared with plate/screw fixation (2/18, 11%) (P=0.01) and underwent greater subsequent procedures (n=5, 63%). Surgeons should consider locked plate and screw fixation as their first treatment choice in this challenging patient population.

LEVEL OF EVIDENCE

III, therapeutic study; retrospective comparative study.

Changing trends in the management of children's fractures

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

Titanium elastic nailing versus hip spica cast in treatment of femoral-shaft fractures in children

Background

There is no consensus on treatment of closed femoral-shaft fractures in children. We compared hip spica cast with titanium elastic nailing (TEN) in the treatment of femoral-shaft fractures in children.

Materials and methods

Forty-six children, 6–12 years old, with simple femoral-shaft fractures were randomized to receive skeletal traction followed by hip spica cast (n = 23) or TEN (n = 23). Length of hospital stay, time to start walking with aids, time to start independent walking, time absent from school, parent satisfaction, and range of knee motion were compared between the two groups 6 months after injury.

Results

The two groups were similar in background characteristics. Compared with the children treated with spica cast, those treated with TEN had shorter hospital stay (P < 0.001) and took a shorter time to start walking with support or independently (P < 0.001), returned to school sooner (P < 0.001), and had higher parent satisfaction (P = 0.003). Range of knee motion was 138.7 ± 3.4° in the spica cast group and 133.5 ± 13.4° in the TEN group (P = 0.078). Three patients (13.0%) in the spica cast group compared with none in the TEN group had malunion (P = 0.117). Postoperative infection was observed in three patients (13.0%) in the TEN group.

Conclusions

The results showed significant benefits of TEN compared with traction and hip spica cast in the treatment of femoral-shaft fractures in children. Further trials with longer follow-ups and comparison of TEN with other methods, such as external fixation, in children’s femoral fractures are warranted.

Flexible intramedullary nailing in paediatric femoral shaft fractures

This retrospective study aims to evaluate the efficacy of flexible intramedullary (IM) nails as a fixation device of paediatric femoral shaft fractures. A total of 36 children with 37 closed fractures were treated by this method. The patients ranged in age from 7.2 to 13.5 years and the mean follow-up was 25.5 months. All patients had open femoral growth plates at the time of surgery. All fractures united and none of the patients needed re-operation. Complications included pain/irritation at the insertion site, superficial wound breakdown and one case of delayed union. No major complications were recorded. After nail removal, all children had full range of hip and knee motion. At final follow-up, although radiographs revealed that 44% of the children had malalignment at the fracture site in one or both planes, none of the children presented with clinical malalignment of the fractured limb. Maximum angulation that was calculated on the coronal plane was 5 degrees into varus and on the sagittal plane 7 degrees of anterior angulation (apex posteriorly). Leg-length discrepancy was assessed clinically and radiographically when needed. A total of 50% of the children had a leg-length inequality but none of them complained of a functional problem. Flexible nailing of diaphyseal fractures of the femur is a reliable method with a small learning curve and allows early mobilisation. Most of our minor complications were technique related and could be avoided.

Treatment of femoral fractures in children: is titanium elastic nailing an improvement over hip spica casting?

PURPOSE

The purpose of the study was to assess the validity of surgical interference with elastic nailing in treating pediatric femur fractures in comparison with the traditional treatment method-hip spica casting.

METHODS

Sixteen consecutive femur fractures in children 5-15 years of age were recruited prospectively over 13 months. An equal number of age-matched children treated by spica casting were recruited retrospectively. Subtrochanteric, supracondylar femur fractures were excluded.

RESULTS

Fracture union occurred earlier in the surgical group (6 weeks) than in the spica group (8 weeks) (P = 0.001). Spica casting caused higher coronal plane angulation (P = 0.001), higher rotational malalignment (P < 0.001), higher limb length discrepancy at 1-year follow-up (P < 0.001), longer duration of immobilization (P < 0.001), later full weight-bearing (P < 0.001), and greater absence from school (P < 0.001). Flynn outcome scores were better with titanium elastic nailing than with hip spica casting.

CONCLUSION

Titanium elastic nailing led to better outcomes compared to hip spica casting in terms of earlier union, lower rates of malunion, shorter rehabilitation milestones, and better functional outcome scores.

OSTEOSYNTHESIS WITH INTRAMEDULLARY NAILS IN CHILDREN

The authors present a comprehensive review of the literature emphasizing the use of flexible intramedullary nails in the treatment of fractures in children, focusing the treatment of femoral shaft and forearm fractures and emphasizing the importance of the non-surgical approach. Children's age and weight threshold are not well defined for the use of the method. The removal of implants is a controversial matter in the literature, with a trend towards keeping the implants.

Flexible interlocked nailing of pediatric femoral fractures: experience with a new flexible interlocking intramedullary nail compared with other fixation procedures

BACKGROUND

The optimal treatment of femoral shaft fractures in older children and adolescents remains controversial. We hypothesized that fixation with a flexible interlocking intramedullary nail (FIIN) reduces perioperative complications and improves outcomes, including leg-length discrepancy, time to healing, and time to weight bearing compared with other fixation procedures (OFPs) including standard elastic nail implants.

METHODS

Using a retrospective cohort study design, we reviewed medical records and radiographs of children, 7 to 18 years of age, with femoral shaft fractures requiring open treatment between July 1, 1998, and June 30, 2003. Patients selected for the study had unilateral fracture sites proximal to the supracondylar region and distal to the lesser trochanter, presence of open femoral growth plates, and open surgical treatment. Analyses compared inpatient measures and patient outcomes between FIIN and OFP groups.

RESULTS

Of the 160 patients eligible for inclusion, 23 were lost to follow-up. The remaining 137 patients had a mean follow-up of 396.3 days (SD, 320.4 days), with 58 receiving FIIN fixation and 79 OFP. Although the difference was not statistically significant, complications occurred in 19.0% of patients in the FIIN group and 30.4% in the OFP group. Trochanteric heterotopic ossification was the most common complication (13.8%) noted in the FIIN group and superficial infection (12.8%) in the OFP group. The FIIN group experienced less blood loss (P = 0.042) and shorter time to weight bearing (P = 0.001) without disturbance of proximal femoral geometry or avascular necrosis of the femoral head. In children weighing less than 45.5 kg (100 lb), complications were less common with FIIN (3.6%) compared with OFP (24.4%). A subgroup of patients less than 45.5 kg (100 lb) with standard elastic nail implants (n = 24) had 8.1 times the complications of patients with FIIN.

CONCLUSIONS

Older children and adolescents with femoral shaft fractures treated with a FIIN showed improved outcomes compared with patients treated with OFP.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Dynamic skeletal traction spica casts for paediatric femoral fractures in a resource-limited setting

The objective of this study was to compare elastic intramedullary nailing (EIN) with dynamic skeletal traction spica casting (DSTSC) in terms of postoperative radiographic angulations, length of hospital stay, and cost in a resource-limited setting. We prospectively studied 51 children, five to twelve years of age, with femoral fractures treated with either EIN (n = 26) or DSTSC (n = 25). Children treated with EIN had significantly longer hospital stays (17 +/- 8.0 days) than those treated with DSTSC (6.0 +/- 2.5 days). Financial constraints in acquiring supplies caused a significant increase in time from admission to surgery (EIN 9.5 +/- 2.3 days; DSTSC 1.1 +/- 0.3 days), and cost was about 400% higher for EIN compared with DSTSC. At twelve weeks follow-up, all patients in both groups had acceptable radiographic angulations. In resource-limited healthcare settings, DSTSC is an effective alternative to EIN with comparable post-op radiographic angulations, decreased hospital stays, and lower cost.

COMPLICATIONS OF INTERNAL FIXATION IN PAEDIATRIC FRACTURES

BACKGROUND

Most displaced fractures in children can be managed by closed treatment. Internal fixation of fractures is sometimes required to achieve satisfactory reduction with certain fractures. The aim of this study was to document the rate of complications associated with internal fixation of fractures in the paediatric age group.

METHODS

A retrospective study was carried out on 268 consecutive children who had internal fixation of fractures from January 2000 to July 2004. The complications were categorized as major or minor.

RESULTS

The average age was 9.2 years (range, 1.4-16.9). There were 327 fractures. Fifty-nine children had fractures of two bones. Humeral fractures accounted for 45.7% of fractures, forearm fractures 31.3%, tibial and fibular fractures 14.1% and femoral fractures 4.9%. There were 27 children (10%) with major complications and 49 children (18%) with minor complications. There were 18 children (6.7%) with both major and minor complications. A total of 66 (24.6%) children had complications. There were 23 children (8.5%) requiring further surgery.

CONCLUSIONS

In this study, 24.6% of children had complications associated with internal fixation. The risk of complications should be considered when electing to proceed with surgical treatment. Closed treatment should always be attempted in children unless there is a good indication for internal fixation.

Use and abuse of flexible intramedullary nailing in children and adolescents

Elastic stable intramedullary nailing (ESIN) has became a well-accepted method of osteosynthesis of diaphyseal fractures in children and adolescents for many reasons including the following: no need for postoperative cast, primary bone union with avoidance of growth plate injury, and minimum invasive surgery.

OPERATIVE TECHNIQUE

The principle is to introduce 2 elastic nails, titanium or stainless steel, into the medullary canal through a metaphyseal approach. The bended nails must have their maximum of curve at the level of the fracture, and their orientation, most often face to face, is in charge of the reduction and, so far, the stabilization, of the fracture. The usual size of the nails is equal to 0.4 times the diameter of the medullary canal. As far as possible, a bigger diameter is better than a thinner one. Most fractures of the femur are treated with a bipolar retrograde ESIN when some distal fractures need an antegrade subtrochanteric approach. Forearm fractures need a combined retrograde radial and antegrade ulnar through the posterolateral part of the olecranon. Humerus and tibial diaphyseal fractures may also be treated with ESIN. Complications are mainly caused by technical errors including too-thin nails, asymmetry of the frame, and malorientation of the implants. Nonunion was never observed in fractures of the femur and the forearm; osteomyelitis rate is 2%, and mean overgrowth of the femur is less than 10 mm before the age of 10 years. Indications of ESIN are fractures of the diaphysis: all the fractures of the femur between the age of 6 years and the end of growth except for the severe open grade III fractures, all the unstable fractures of the forearm, and some unstable fractures of the humerus and the tibia during adolescence or before the end of growth. In addition, ESIN is indicated in polytraumatism and multiple injuries.

CONCLUSIONS

The good results of this reliable technique are obtained when surgeons have a good knowledge of it, especially in the understanding of the principle of the correction of the fracture and its stability.

Fractured neck of femur in a child after femoral fracture fixation by intramedullary flexible nails: a case report

Since the introduction of flexible intramedullary nails, the treatment of femoral shaft fractures in adolescents has been revolutionized and this has become the routine treatment in most units, with minimal complications. We report a rare complication of an ipsilateral fractured neck of femur in a fit and healthy 12-year-old girl 6 months after treatment of a traumatic fractured femoral shaft; this was treated effectively with cannulated screws and the patient was successfully discharged without any further complication.

Spica cast application in the emergency room for select pediatric femur fractures

OBJECTIVES

This study was designed to evaluate the efficacy and safety of immediate spica casting in the emergency room (ER) and evaluate the effect of discharge from the emergency room on short- term complications.

DESIGN

Retrospective review of patients treated with immediate spica casting in the ER between June 1, 1993 and July 30, 2001.

SETTING

Major, pediatric, orthopaedic trauma and referral center.

PATIENTS

A total of 145 pediatric femur fractures in children, younger than age 7 years, treated with immediate spica casting in the ER were reviewed to determine radiographic outcome and short-term complication rates.

INTERVENTION

All patients underwent immediate spica cast placement in the ER under conscious sedation. Patients meeting specific criteria were discharged immediately from the ER.

MAIN OUTCOME MEASUREMENTS

Radiographic acceptability of alignment at fracture union (angulation, shortening), loss of reduction, number of return visits to the emergency room, and clinical outcome at final follow-up.

RESULTS

Average follow-up was 20 +/- 16 weeks (range, 1-9 months). Forty-eight patients (33%) were discharged from the ER. No clinical complications were noted at last follow-up. All children younger than age 2 years, and 86.5% of children ages 2 to 5 years, met acceptable malalignment parameters on final radiographs. There were 16 ER visits (11%) for cast problems. Re-reduction in the operating room was needed in 11 patients (8.9%); 6.9% of patients had a cast problem noted during follow-up visits. Only 9% of patients developed a major complication. Initial shortening was the only independent risk factor found to be associated with loss of reduction. Admission status had no significant effect on the number of ER visits or development of a complication.

CONCLUSIONS

If there are no associated factors requiring admission (ie, child abuse or polytrauma), spica casting in the ER for pediatric femur fractures followed by immediate discharge can be safely performed with a low complication rate in children younger than age 6 years, nearly eliminating the need for general anesthesia.

Operative treatment of femoral shaft fractures in children and adolescents

Although femoral shaft fractures constitute fewer than 2% of all fractures in children and adolescents, their treatment has produced many pieces of literature and years of controversy. Prevailing opinion has favored nonoperative and operative treatment, and a variety of techniques have been advocated to avoid complications such as nonunion, limb-length discrepancy, malalignment, osteonecrosis, and growth disturbance. Currently, operative methods of treatment generally are favored to allow early ambulation and shorter hospital stays and to avoid detrimental psychological and social effects often associated with prolonged nonoperative treatment, and to avoid complications. Options for operative fixation include external fixators, flexible and locked intramedullary nails, and compression and bridge plating. Although all of these can obtain good results in particular situations, there is no clear consensus of the indications for each. My choice for fixation of each fracture is based on consideration of a number of factors, including the age and size of the child, associated injuries, the location and pattern of the fracture, and the social situation of the child. In general, I prefer flexible nailing for younger children (6-10 years old) and locked nailing for adolescents at or near skeletal maturity. Bridge plating may be chosen for segmental, grossly comminuted fractures, whereas external fixation usually is reserved for severely comminuted or severe open fractures for which internal fixation is not appropriate.

Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children

BACKGROUND

Titanium elastic nails are commonly used to stabilize femoral fractures in school-aged children, but there have been few studies assessing the risks and benefits of this procedure compared with those of traditional traction and application of a spica cast. This prospective cohort study was designed to evaluate these two methods of treatment, with a specific focus on the first year after injury, the period when the treatment method should have the greatest impact.

METHODS

Eighty-three consecutive children, six to sixteen years of age, were studied prospectively. Factors that were analyzed included clinical and radiographic data, complications, hospital charges, and outcome data. Outcome and recovery were assessed both with the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collections Instrument, version 2.0, and according to a series of important recovery milestones including the time to walking with aids, time to independent walking, time absent from school, and time until full activity was allowed.

RESULTS

Thirty-five children (thirty-five fractures), with a mean age of 8.7 years, were treated with traction and application of a spica cast, and forty-eight children (forty-nine fractures), with a mean age of 10.2 years, were treated with titanium elastic nails. All fractures healed, and no child sustained a complication that was expected to cause permanent disability. At one year after the fracture, eighty of the children had acceptable alignment and no inequality between the lengths of the lower extremities. The remaining three children, who had an unsatisfactory result, had been treated with traction and a spica cast. Twelve patients (34%) treated with traction and a cast had a complication compared with ten patients (21%) treated with titanium elastic nails. Compared with the children treated with traction and a cast, those treated with titanium elastic nails had shorter hospitalization, walked with support sooner, walked independently sooner, and returned to school earlier. These differences were significant (p < 0.0001). We could detect no difference in total hospital charges between the two groups.

CONCLUSIONS

The results of this prospective study support the recent empiric observations and published results of retrospective series indicating that a child in whom a femoral fracture is treated with titanium elastic nails achieves recovery milestones significantly faster than a child treated with traction and a spica cast. Hospital charges for the two treatment methods are similar. The complication rate associated with nailing compares favorably with that associated with traction and application of a spica cast.

Surgical treatment of pediatric femoral shaft fractures

PURPOSE OF REVIEW

Femoral shaft fractures are among the most common fractures in children. Depending on the patient's age, fracture location, pattern, mechanism of injury, and associated injuries, several different treatment options exist. The purpose of this review is to discuss these different clinical situations and the recommended treatment methods, as well as to characterize the latest literature and recommendations.

RECENT FINDINGS

In the past several years, there have been significant changes in the approach to the treatment of pediatric femoral shaft fractures, particularly in school-aged children. Young children have traditionally been treated conservatively with good results, and this method is still currently advocated. Adolescents over the age of 12 are generally treated with rigid intramedullary rods. However, in children between the ages of 5 and 12, new surgical treatment modalities have been tested with good outcomes, and, as new data emerge, these methods are becoming preferable to conservative treatment.

SUMMARY

Children who sustain femoral shaft fractures can present difficult challenges to both orthopedists and pediatricians. A recent shift in treatment in children between ages of 5 and 12 from nonoperative to surgical intervention has led to shorter hospital stays and earlier return to activity with reliable fracture healing.