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Wu J, Shen X, Wang T, Li J, Chen X, Lei Y, Tang B, Zhang P. Ultrasound-guided techniques for managing length- unstable femoral shaft fractures in children. BMC Musculoskelet Disord 2024; 25:622. [PMID: 39103800 DOI: 10.1186/s12891-024-07740-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/26/2024] [Indexed: 08/07/2024] Open
Abstract
OBJECTIVE The management of length-unstable femoral shaft fractures(LUFSFs) in pediatric patients is still controversial. This study aims to explore the clinical efficacy of ultrasound-guided closed reduction combined with external fixation for treating LUFSFs in children. METHODS We conducted a retrospective analysis of clinical data from 19 pediatric patients with LUFSFs who underwent ultrasound-guided closed reduction and external fixation between January 2018 and January 2023. Ultrasound was employed not only to facilitate closed reduction of the fracture but also to guide real-time insertion of Schanz pins and monitor pin length as it traversed the opposite cortex. Surgical time, intraoperative fluoroscopy count, hospital stay length, fracture fixation duration, complication incidence, fracture reduction quality at the final follow-up were recorded. RESULTS The patients' average age was 7.5 years( range: 5 to 11 years). The mean surgical duration was 70.4 min (range: 48-105 min), and the average intraoperative fluoroscopy count was 6.5 (range: 2-16). Fracture fixation lasted an average of 10.9 weeks (range: 7-20 weeks). All patients were followed up for more than one year. 6 cases of superficial pin tract infection occurred, which resolved with oral antibiotics and enhanced needle tract care. No deep infections were observed. Temporary stiffness of the knee joint was observed in 2 patients. According to Flynn's efficacy evaluation system, fracture reduction quality at the final follow-up was rated as excellent in 11 cases and satisfactory in 8 cases, yielding a combined success rate of 100% (19/19). CONCLUSIONS The technique of ultrasound-guided closed reduction combined with external fixation offers favorable outcomes for children aged 5 to 11 years with LUFSFs, reducing reliance on fluoroscopic guidance.
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Affiliation(s)
- Ji Wu
- Department of Pediatric Orthopedics, Wuhan Children's Hospital(Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, 100 Xianggang Road, Jiang'an District, Wuhan, China
| | - Xiantao Shen
- Department of Pediatric Orthopedics, Wuhan Children's Hospital(Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, 100 Xianggang Road, Jiang'an District, Wuhan, China
| | - Teng Wang
- Department of Pediatric Orthopedics, Wuhan Children's Hospital(Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, 100 Xianggang Road, Jiang'an District, Wuhan, China
| | - Jun Li
- Department of Pediatric Orthopedics, Wuhan Children's Hospital(Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, 100 Xianggang Road, Jiang'an District, Wuhan, China
| | - Xiaoliang Chen
- Department of Pediatric Orthopedics, Wuhan Children's Hospital(Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, 100 Xianggang Road, Jiang'an District, Wuhan, China
| | - Yuanxue Lei
- Department of Pediatric Orthopedics, Wuhan Children's Hospital(Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, 100 Xianggang Road, Jiang'an District, Wuhan, China
| | - Bingrong Tang
- Department of Medical Record Statistics, Wuhan Children's Hospital(Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, 100 Xianggang Road, Jiang'an District, Wuhan, China.
| | - Ping Zhang
- Department of Pediatric Orthopedics, Wuhan Children's Hospital(Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, 100 Xianggang Road, Jiang'an District, Wuhan, China.
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Muacevic A, Adler JR, Kraft D, Mathur A, Ramamurti P, Tabaie S. Racial Disparities in Outcomes Following Open Treatment of Pediatric Femoral Shaft Fractures. Cureus 2022; 14:e33149. [PMID: 36601175 PMCID: PMC9803589 DOI: 10.7759/cureus.33149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2022] [Indexed: 01/01/2023] Open
Abstract
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.
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Lakhani A, Bhatnagar SM, Singh GP, Gupta N, Sharma E. Role of mini-invasive bridge plate in the complex femoral fracture in school going children: A prospective clinical study of 30 cases. J Family Med Prim Care 2021; 10:1188-1192. [PMID: 34041149 PMCID: PMC8140261 DOI: 10.4103/jfmpc.jfmpc_1210_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 12/02/2022] Open
Abstract
Objective: Pediatric femoral fracture including supracondylar and subtrochanteric fracture constitutes 1.6% of all paediatric fracture. Elastic nails remain the standard treatment of choice in a midshaft transverse femoral fracture in children weighing less than 45 kg. But in subtrochanteric and spiral femoral fracture, the failure rate of elastic nails are quite high. Hence, in accordance with AAOS guidelines, we treated complex femoral fracture in children with submuscular mini-invasive bridge plate because of its advantage of minimal incision, early union with proper alignment and lower failure. Material and Methods: We retrospectively reviewed 30 complex femur fracture in children treated with Submuscular bridge plate by mini-invasive approach. Patients were analysed according to their age, type of fracture, time of union in weeks, complication and results were evaluated with modified Flynn's criteria. Result: Out of 30 patients 28 were boys and 2 were females, with an average age of 11.5 years in which Spiral fracture (n = 12), subtrochanteric fracture (n = 9), Complex Shaft fracture (n = 10). All fracture united well on an average of 11 weeks. And 29 patients has excellent results and in 1 patient there is Acceptable result. The single complication was 3 mm limb lengthening but it didn't change gait of the patient. Conclusion: Mini invasive bridge plating is an easy and soft tissue preserving procedure for managing complex femoral fracture in children. It has shown promising results in achieving union without any major complication. We strongly recommend the SBP in a complex femoral fracture in children.
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Affiliation(s)
- Amit Lakhani
- Department of Orthopedics, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti Solan, Mullana, Ambala, Haryana, India
| | - S M Bhatnagar
- Department of Orthopedics, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti Solan, Mullana, Ambala, Haryana, India
| | - Gobind Pratap Singh
- Department of Orthopedics, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti Solan, Mullana, Ambala, Haryana, India
| | - Nikunj Gupta
- Department of Orthopedics, Maharishi Markandeshwar Medical College and Hospital, Kumarhatti Solan, Mullana, Ambala, Haryana, India
| | - Ena Sharma
- Department of Periodontics, Maharishi Markandeshwar College of Dental Sciences and Research, Mullana, Ambala, Haryana, India
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Mussell EA, Jardaly A, Gilbert SR. Length unstable femoral fractures: A misnomer? World J Orthop 2020; 11:380-390. [PMID: 32999858 PMCID: PMC7507079 DOI: 10.5312/wjo.v11.i9.380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/28/2020] [Accepted: 08/16/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Flexible intramedullary nailing (FIMN) is relatively contraindicated for pediatric length unstable femoral fractures.
AIM To evaluate FIMN treatment outcomes for pediatric diaphyseal length unstable femoral fractures in patients aged 5 to 13 years.
METHODS This retrospective study includes pediatric patients (age range 5-13 years) who received operative treatment for a diaphyseal femoral fracture at a single institution between 2013 and 2019. Length unstable femur fractures treated with FIMN were compared to treatment with other fixation methods [locked intramedullary nailing (IMN), submuscular plating (SMP), and external fixation] and to length stable fractures treated with FIMN. Exclusion criteria included patients who had an underlying predisposition for fractures (e.g., pathologic fractures or osteogenesis imperfecta), polytrauma necessitating intensive care unit care and/or extensive management of other injuries, incomplete records, or no follow-up visits. Patients who had a length stable femoral fracture treated with modalities other than FIMN were excluded as well.
RESULTS Ninety-five fractures from ninety-two patients were included in the study and consists of three groups. These three groups are length unstable fractures treated with FIMN (n = 21), length stable fractures treated with FIMN (n = 45), and length unstable fractures treated with either locked IMN, SMP, or external fixator (n = 29). P values < 0.05 were considered statistically significant. Patient characteristic differences that were statistically significant between the groups, length unstable with FIMN and length unstable with locked IMN, SMP, or external fixator, were average age (7.4 years vs 9.3 years, respectively), estimated blood loss (29.2 mL vs 98 mL, respectively) and body mass (27.8 kg vs 35.1 kg, respectively). All other patient characteristic differences were statistically insignificant. Regarding complications, length unstable with FIMN had 9 total complications while length unstable with locked IMN, SMP, or external fixator had 10. Grouping these complications into minor or major, length unstable with locked IMN, SMP, or external fixator had 6 major complication while length unstable with FIMN had 0 major complications. This difference in major complications was statistically significant. Lastly, when comparing patient characteristics between the groups, length unstable with FIMN and length stable with FIMN, all characteristics were statistically similar except time to weight bearing (39 d vs 29 d respectively). When analyzing complication differences between these two groups (9 total complications, 0 major vs 20 total complications, 4 major), the complication rates were considered statistically similar.
CONCLUSION FIMN is effective for length unstable fractures, having a low rate of complications. FIMN is a suitable option for length stable and length unstable femur fractures alike.
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Affiliation(s)
- Eric Andrew Mussell
- Department of Orthopaedic Surgery, University of Alabama at Birmingham, and Andrews Sports Medicine and Orthopaedic Center, Birmingham, AL 35205, United States
| | - Achraf Jardaly
- Department of Orthopedic Surgery, University of Alabama at Birmingham and Lebanese American University, Gilbert and Rose-Marie Chagoury School of Medicine, Byblos 00000, Lebanon
| | - Shawn R Gilbert
- Department of Pediatric Orthopaedics, University of Alabama at Birmingham, Birmingham, AL 35233, United States
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Milligan D, Henderson L, Tucker A, Ballard J. Elastic nail fixation versus plate fixation of paediatric femoral fractures in school age patients - A retrospective observational study. J Orthop 2020; 19:153-157. [PMID: 32025124 PMCID: PMC6997651 DOI: 10.1016/j.jor.2019.11.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 11/24/2019] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- D. Milligan
- C/O Fracture Clinic, Royal Belfast Hospital for Sick Children, Falls Road, Belfast, Northern Ireland, BT12 6BE, UK
| | - L. Henderson
- C/O Fracture Clinic, Royal Belfast Hospital for Sick Children, Falls Road, Belfast, Northern Ireland, BT12 6BE, UK
| | - A. Tucker
- C/O Fracture Clinic, Royal Belfast Hospital for Sick Children, Falls Road, Belfast, Northern Ireland, BT12 6BE, UK
| | - J. Ballard
- Royal Belfast Hospital for Sick Children, Falls Road, Belfast, Northern Ireland, BT12 6BE, UK
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Yang J, Wang T, Tian NF, Yu XB, Chen H, Wu YS, Sun LJ. Supracondylar humeral fractures in children: American Academy of Orthopaedic Surgeons appropriate use criteria versus actual management in a teaching hospital. J Child Orthop 2019; 13:404-408. [PMID: 31489047 PMCID: PMC6701448 DOI: 10.1302/1863-2548.13.190081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The objective of this study was to explore whether there were any differences between the theoretical recommendations for children's supracondylar humeral fractures (CSHF) according to the American Academy of Orthopaedic Surgeons (AAOS) guidelines and the treatments they actually received in our institution. METHODS We retrospectively reviewed the medical charts and radiographs of all CSHFs at our hospital between January 2015 and December 2018. In all, 301 children meeting our inclusion criteria were identified and evaluated using the AAOS-Appropriate Use Criteria (AUC) application for supracondylar humerus fractures. Actual treatment was then compared with the treatment recommended by the AUC. RESULTS Actual operative management was undertaken in 0/58 (0%) Gartland type I fractures, 61/108 (56.5%) type II fractures and 98/135 (72.6%) type III fractures. Actual nonoperative management was undertaken in 58/58 (100%) Gartland type I fractures, 47/108 (43.5%) type II fractures and 37/135 (27.4%) type III fractures. Surgeon decisions for nonoperative treatment were in agreement with the AUC recommendations 100% of the time, whereas surgeon decisions for surgery matched the AUC recommendations 65.4% of the time. Predictors of actual operative management were age (p =0.003), fracture classification (p =0.000), associated orthopaedic injury requiring surgery (p =0.025) and anterior humeral line (AHL) not intersecting the capitellum (p =0.008). CONCLUSION We found low agreement between actual treatments and the AUC-recommended 'appropriate' treatments. The AUC favoured operative intervention more frequently largely on the basis of fracture classification while we emphasized age, fracture classification, associated orthopaedic injury requiring surgery and alignment of the AHL with the capitellum in our operative decision-making process. LEVEL OF EVIDENCE Therapeutic Level II.
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Affiliation(s)
- J. Yang
- Department of Orthopaedic Surgery, Zhuji Central Hospital, Zhuji, Zhejiang, China
| | - T. Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, and Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, Zhejiang, China
| | - N.-F. Tian
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, and Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, Zhejiang, China
| | - X.-Bin Yu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, and Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, Zhejiang, China
| | - H. Chen
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, and Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, Zhejiang, China
| | - Y.-S. Wu
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, and Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, Zhejiang, China,Correspondence should be sent to: Y-S. Wu, Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou 325000, China. E-mail:
| | - L.-J. Sun
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, and Zhejiang Provincial Key Laboratory of Orthopaedics, Wenzhou, Zhejiang, China,Correspondence should be sent to: L-J. Sun, Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, 109 Xueyuanxi Road, Wenzhou 325000, China. E-mail:
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Vitiello R, Lillo M, Donati F, Masci G, Noia G, De Santis V, Maccauro G. Locking plate fixation in pediatric femur fracture: evaluation of the outcomes in our experience. ACTA BIO-MEDICA : ATENEI PARMENSIS 2019; 90:110-115. [PMID: 30715008 PMCID: PMC6503420 DOI: 10.23750/abm.v90i1-s.8109] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 02/08/2023]
Abstract
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 (varovalgus 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.
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Han B, Wang Z, Li Y, Xu Y, Cai H. Risk factors for refracture of the forearm in children treated with elastic stable intramedullary nailing. INTERNATIONAL ORTHOPAEDICS 2018; 43:2093-2097. [PMID: 30280215 DOI: 10.1007/s00264-018-4184-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 09/24/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE This study aims to investigate risk factors for refracture of the forearm in children treated with elastic stable intramedullary nailing (ESIN). METHODS Clinical data of 267 patients who had been treated for forearm fractures by ESIN in our hospital from January 2010 to December 2014 were retrospectively reviewed. Risk factors for forearm refractures were determined using logistic regression analysis. RESULTS Forearm refractures occurred in 11 children. Univariate analysis revealed that age, body weight, number of fractures, open fracture, nail diameter, and immobilization time were not associated with refractures. However, gender (male, P = 0.042) and fracture location (lower third, P = 0.007) were significantly associated with refractures. Multivariate analysis revealed that fracture location was an independent risk factor for forearm refractures (P = 0.031). CONCLUSION Forearm refracture is uncommon in children treated with ESIN. Fracture location is an independent risk factor for forearm refractures in these patients.
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Affiliation(s)
- Bingqiang Han
- Department of Pediatric Orthopedics, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127, People's Republic of China
| | - Zhigang Wang
- Department of Pediatric Orthopedics, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127, People's Republic of China
| | - Yuchan Li
- Department of Pediatric Orthopedics, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127, People's Republic of China
| | - Yunlan Xu
- Department of Pediatric Orthopedics, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127, People's Republic of China
| | - Haiqing Cai
- Department of Pediatric Orthopedics, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127, People's Republic of China.
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Clinical and Radiographic Outcomes After Submuscular Plating (SMP) of Pediatric Femoral Shaft Fractures. J Pediatr Orthop 2018; 38:138-143. [PMID: 27261971 DOI: 10.1097/bpo.0000000000000780] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND To evaluate lower extremity strength and alignment among children who underwent submuscular plating (SMP). METHODS Subjects who underwent SMP for a length unstable femoral fracture returned for isokinetic strength testing ≥2 years after surgery. Extensor and flexor strength deficits (percent difference) between the operative and nonoperative limbs were evaluated. Radiographic measurements of mechanical alignment [anatomic lateral distal femoral angle (aLDFA)] and qualitative measurements (The Pediatric Outcomes Data Collection Instrument, PODCI) were obtained from all subjects. The upper 97.5% confidence interval approach to establishing clinical equivalency was utilized to compare differences in strength and alignment between the operative and nonoperative limbs. An extensor strength deficit of >19% and an aLDFA discrepancy of >5 degrees were considered to be clinically significant. RESULTS The average age at surgery of the 10 subjects included in the study was 8.7 years. The hardware was placed an average of 27.9 mm from the distal femoral physis and was removed 6.4 months postsurgery. Among all subjects, the median PODCI scores were ≥97 according to all subscales. There was no significant difference in extension torque between the operative versus nonoperative limbs at 60 degrees/s (P=0.5400), 120 degrees/s (P=0.4214), or 180 degrees/s (P=0.8166). More importantly, extension strength deficits between the operative and nonoperative limbs were not clinically significant at 60 degrees/s [upper 97.5% confidence interval (CI), 10.9%], 120 degrees/s (upper 97.5% CI, 11.0%), or 180 degrees/s (upper 97.5% CI, 10.7%). The difference in aLDFA between the operative and nonoperative limb was less than the predefined clinically significant threshold of 5 degrees for all subjects. CONCLUSIONS SMP achieves satisfactory clinical and functional results. In this series, extensor strength deficits and/or lower extremity malalignment were not clinically meaningful. High patient satisfaction can be expected after implant removal. LEVEL OF EVIDENCE Level IV-case series.
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Stenroos A, Laaksonen T, Nietosvaara N, Jalkanen J, Nietosvaara Y. One in Three of Pediatric Tibia Shaft Fractures is Currently Treated Operatively: A 6-Year Epidemiological Study in two University Hospitals in Finland Treatment of Pediatric Tibia Shaft Fractures. Scand J Surg 2018; 107:269-274. [PMID: 29291697 DOI: 10.1177/1457496917748227] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Internal fixation of pediatric tibia shaft fractures has become increasingly popular despite the fact that non-operative treatment results in satisfactory outcome with few exceptions. Indications for surgery and benefits of internal fixation are however still debatable. MATERIALS AND METHODS All 296 less than 16-year-old patients treated for a tibia shaft fracture between 2010 and 2015 in two of the five university hospitals in Finland were included in the study. Patient data were analyzed in three treatment groups: cast immobilization in emergency department, manipulation under anesthesia, and operative treatment. Incidence of operative treatment of pediatric tibia shaft fractures was calculated in the cities of Helsinki and Kuopio. RESULTS A total of 143 (47.3%) children's tibia shaft fractures were treated with casting in emergency department, 71 (22.3%) with manipulation under anesthesia, and 82 (30.4%) with surgery. Mean age of the patients in these treatment groups was 6.2, 8.7, and 12.7 years. Fibula was intact in 89%, 51%, and 27% of the patients, respectively. All 6 patients with multiple fractures and 16 of 18 patients with open fractures were treated operatively. In eight patients, primary non-operative treatment was converted to internal fixation. Operatively treated patients with isolated closed fractures were more likely to have a fibula fracture (46/66 vs 52/214, p < 0.001), be older in age (13.08 ± 2.4 vs 6.4 ± 3.7, p < 0.001), and have more primary angulation (6.9 ± 5.8 vs 0.48 ± 3.1, p < 0.001). Re-operations were done to eight and corrective osteotomy to two operatively treated children. CONCLUSION Operative treatment of a pediatric tibia shaft fracture is currently nearly a rule in patients with open or multiple fractures. Surgical treatment of closed tibia shaft fractures is based on surgeon's personal preference, type of fracture and age of the patient.
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Affiliation(s)
- A Stenroos
- 1 Department of Orthopedics and Traumatology, Helsinki University Central Hospital, Helsinki, Finland
| | - T Laaksonen
- 2 Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
| | - N Nietosvaara
- 3 Department of Pediatric Surgery, Kuopio University Hospital, Kuopio, Finland
| | - J Jalkanen
- 3 Department of Pediatric Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Y Nietosvaara
- 2 Children's Hospital, Helsinki University Central Hospital, Helsinki, Finland
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Elsey NM, Tobias JD, Klingele KE, Beltran RJ, Bhalla T, Martin D, Veneziano G, Rice J, Tumin D. A prospective, double-blinded, randomized comparison of ultrasound-guided femoral nerve block with lateral femoral cutaneous nerve block versus standard anesthetic management for pain control during and after traumatic femur fracture repair in the pediatric population. J Pain Res 2017; 10:2177-2182. [PMID: 28919813 PMCID: PMC5590772 DOI: 10.2147/jpr.s139106] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Traumatic injury of the femur resulting in femoral fracture may result in significant postoperative pain. As with other causes of acute pain, regional anesthesia may offer a benefit over conventional therapy with intravenous opioids. This study prospectively assesses the effects of femoral nerve blockade with a lateral femoral cutaneous nerve block (FN-LFCN) on intraoperative anesthetic requirements, postoperative pain scores, and opioid requirements. Materials and methods Seventeen pediatric patients (age 2–18 years) undergoing surgical repair of a traumatic femur fracture fulfilled the study criteria and were randomly assigned to general anesthesia with either an FN-LFCN block (n = 10) or intravenous opioids (n = 7). All patients received a general anesthetic with isoflurane for maintenance anesthesia during the surgical repair of the femur fracture. Patients randomized to the FN-LFCN block group received ultrasound-guided nerve blockade using ropivacaine (0.2%/0.5% based on patient weight). At the conclusion of surgery, the airway device was removed once tracheal extubation criteria were achieved, and patients were transported to the post-anesthesia care unit (PACU) for recovery and assessment of pain by a blinded study nurse. Results The final study cohort included 17 patients (n = 10 for FN-LFCN block group; n = 7 for the intravenous opioid group). Although the median of the maximum postoperative pain scores in the regional group was 0, this did not reach statistical significance when compared to the median pain score of 3 in the intravenous opioid group. Likewise, no difference between the two groups was noted when comparing intraoperative anesthetic requirements, opioid requirements (intraoperative, in the post-anesthesia recovery room, and in the inpatient ward), and the time to first opioid requirement postoperatively in the inpatient ward. Conclusion This prospective, randomized, double-blinded study failed to demonstrate a clear benefit of regional anesthesia over intravenous opioids intraoperatively and postoperatively during repair of femoral shaft fractures in the pediatric population.
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Affiliation(s)
- Nicole M Elsey
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital.,The Ohio State University.,Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University College of Medicine
| | - Kevin E Klingele
- Department of Orthopedic Surgery and Sports Medicine, Nationwide Children's Hospital and The Ohio State University, Columbus, OH, USA
| | - Ralph J Beltran
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital.,The Ohio State University
| | - Tarun Bhalla
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital.,The Ohio State University
| | - David Martin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital.,The Ohio State University
| | - Giorgio Veneziano
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital.,The Ohio State University
| | - Julie Rice
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital.,The Ohio State University
| | - Dmitry Tumin
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital.,The Ohio State University
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Abstract
The treatment of pediatric diaphyseal femur fractures, particularly length-unstable fractures, continues to be an area of controversy in patients from age 6 to skeletal maturity. Submuscular bridge plating is an alternative that allows for stable internal fixation while minimizing soft tissue disruption. We describe a surgical technique that has simplified both implantation and removal. This technique provides a stable construct in comminuted and unstable fracture patterns allowing for early mobilization with minimal complications.
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Submuscular plating for pediatric femoral fractures. Indications and technique. CURRENT ORTHOPAEDIC PRACTICE 2015. [DOI: 10.1097/bco.0000000000000178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Recent advances in external fixation technique and pin design have sought to minimize complications such as pin site infection and premature removal of the external fixator. Although newer forms of internal fixation have gained popularity, external fixation may still have a role in managing pediatric femoral shaft fractures. QUESTIONS/PURPOSES We sought to assess the time to healing, limb alignment, and complications observed in a cohort of pediatric patients with closed femoral shaft fractures who were treated with external fixation. METHODS Over a 15-year period, one surgeon treated 289 pediatric patients with femur fractures, 31 (11%) of whom received an external fixator. The general indications for use of an external fixator during the period in question included length-unstable fractures, metadiaphyseal location, refracture, and pathologic fracture. Six patients (19%) had inadequate followup data and four patients (13%) were treated with a combination of flexible intramedullary nails and external fixation, leaving 21 patients for analysis. Mean age at injury was 10 years (range, 6-15 years) and followup averaged 22 months (range, 5-45 months) after removal of the fixator. Radiographs were examined for alignment and limb length discrepancy. Complications were recorded from a chart review. RESULTS Mean time in the fixator was 17 weeks (range, 9-24 weeks). One patient sustained a refracture and one patient with an isolated femur fracture had a leg length discrepancy > 2 cm. There were no pin site infections requiring intravenous antibiotics or additional surgery. One patient with Blount disease and previous tibial osteotomy developed transient peroneal nerve palsy. CONCLUSIONS Despite improvements in pin design and predictable fracture healing, complications such as refracture and leg length discrepancy after external fixation of pediatric femoral shaft fractures can occur. However, external fixation remains a viable alternative for certain fractures such as length-unstable fractures, metadiaphyseal location, pathologic fractures, and refractures. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Heather Kong
- Department of Orthopaedic Surgery, Rutgers University-New Jersey Medical School, Doctor's Office Center, 90 Bergen Street Suite 7300, Newark, NJ, 07103, USA,
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15
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Nayagam S, Davis B, Thevendran G, Roche AJ. Medial submuscular plating of the femur in a series of paediatric patients: a useful alternative to standard lateral techniques. Bone Joint J 2014; 96-B:137-42. [PMID: 24395325 DOI: 10.1302/0301-620x.96b1.28691] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe the technique and results of medial submuscular plating of the femur in paediatric patients and discuss its indications and limitations. Specifically, the technique is used as part of a plate-after-lengthening strategy, where the period of external fixation is reduced and the plate introduced by avoiding direct contact with the lateral entry wounds of the external fixator pins. The technique emphasises that vastus medialis is interposed between the plate and the vascular structures. A total of 16 patients (11 male and five female, mean age 9.6 years (5 to 17)), had medial submuscular plating of the femur. All underwent distraction osteogenesis of the femur with a mean lengthening of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation of the regenerate without deformity. The mean follow-up was 10.5 months (7 to 15) after plating for those with plates still in situ, and 16.3 months (1 to 39) for those who subsequently had their plates removed. None developed a deep infection. In two patients a proximal screw fractured without loss of alignment; one patient sustained a traumatic fracture six months after removal of the plate. Placing the plate on the medial side is advantageous when the external fixator is present on the lateral side, and is biomechanically optimal in the presence of a femoral defect. We conclude that medial femoral submuscular plating is a useful technique for specific indications and can be performed safely with a prior understanding of the regional anatomy.
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Affiliation(s)
- S Nayagam
- Royal Liverpool Children's Hospital, Department of Paediatric Orthopaedic Surgery, Alder Hey, Eaton Road, Liverpool L12 2AP, UK
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Kaiser MM, Stratmann C, Zachert G, Schulze-Hessing M, Gros N, Eggert R, Rapp M. Modification of elastic stable intramedullary nailing with a 3rd nail in a femoral spiral fracture model - results of biomechanical testing and a prospective clinical study. BMC Musculoskelet Disord 2014; 15:3. [PMID: 24397612 PMCID: PMC4029588 DOI: 10.1186/1471-2474-15-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 12/31/2013] [Indexed: 11/15/2022] Open
Abstract
Background Elastic stable intramedullary nailing (ESIN) is the standard treatment for displaced diaphyseal femoral fractures in children. However, high complication rates (10-50%) are reported in complex fractures. This biomechanical study compares the stiffness with a 3rd nail implanted to that in the classical 2C-shaped configuration and presents the application into clinical practice. Methods For each of the 3 configurations of ESIN-osteosynthesis with titanium nails eight composite femoral grafts (Sawbones®) with an identical spiral fracture were used: 2C configuration (2C-shaped nails, 2 × 3.5 mm), 3CM configuration (3rd nail from medial) and 3CL configuration (3rd nail from lateral). Each group underwent biomechanical testing in 4-point bending, internal/external rotation and axial compression. Results 2C and 3CM configurations showed no significant differences in this spiroid type fracture model. 3CL had a significantly higher stiffness during anterior-posterior bending, internal rotation and 9° compression than 2C, and was stiffer in the lateral-medial direction than 3CM. The 3CL was less stable during p-a bending and external rotation than both the others. As biomechanical testing showed a higher stability for the 3CL configuration in two (a-p corresponding to recurvation and 9° compression to shortening) of three directions associated with the most important clinical problems, we added a 3rd nail in ESIN-osteosynthesis for femoral fractures. 11 boys and 6 girls (2.5-15 years) were treated with modified ESIN of whom 12 were ‘3CL’; due to the individual character of the fractures 4 patients were treated with ‘3CM’ (third nail from medial) and as an exception 1 adolescent with 4 nails and one boy with plate osteosynthesis. No additional stabilizations or re-operations were necessary. All patients achieved full points in the Harris-Score at follow-up; no limb length discrepancy occurred. Conclusion The 3CL configuration provided a significantly higher stiffness than 2C and 3CM configurations in this biomechanical model. These results were successfully transmitted into clinical practice. All children, treated by 3CL or 3CM according to the individual character of each fracture, needed no additional stabilization and had no Re-Do operations. As a consequence, at our hospital all children with femoral diaphyseal fractures with open physis are treated with this modified ESIN-technique.
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Affiliation(s)
- Martin M Kaiser
- Department of Pediatric Surgery, University Medical Centre Schleswig-Holstein, Campus Luebeck, Ratezburger Allee 160, 23538 Lübeck, Germany.
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Abstract
BACKGROUND Submuscular bridge plating has become an acceptable method of treatment for pediatric femur fractures. The purpose of our study was to describe a technique for submuscular bridge plating and review a series of consecutive, length-unstable, pediatric femur fractures treated at a single institution with this technique. METHODS We performed a query of hospital records from January 4, 2006, to May 10, 2011, to identify length-unstable femur fractures treated with submuscular bridge plating by 5 pediatric surgeons. Included were patients treated with submuscular bridge plating for a femur fracture. Excluded were patients with incomplete medical records, inadequate radiographs, or follow-up <6 months duration. Fifty-one patients met diagnostic criteria; 19 patients were excluded due to incomplete medical records and/or radiographs. RESULTS The study cohort included 32 patients with 33 femur fractures. There were 15 left femurs and 18 right femurs, including 1 bilateral fracture patient. Fracture pattern was composed of 13 comminuted, 5 spiral, 9 long oblique, and 6 short oblique. Mechanisms of injury included: fall from height (8), recreation (23), and MVA (2). Mean time for full weightbearing was 8.1 weeks (range, 3 to 17.6 wk). All patients were radiographically healed by their 12-week assessment. There were no intraoperative complications. Implant removal occurred in 26 patients. There were 2 cases of a broken screw discovered upon implant removal. The remnant screw was not removed in either case. The mean follow-up time for those with implant removal was 43.6 weeks (range, 27 to 83 wk). The 11 patients without implant removal had a mean follow-up time of 38.6 weeks (range, 31.6 to 50 wk). There were no cases of varus or valgus malalignment >10 degrees. One patient experienced implant irritation. There were no cases of wound infections. CONCLUSIONS Our technique of surgical intervention has simplified both implantation and removal, and produced comparable and excellent healing rates, low complication rates, and early return to full weightbearing. LEVEL OF EVIDENCE Level IV, case series.
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Dodd A, Paolucci EO, Parsons D. Paediatric femoral shaft fractures: what are the concomitant injuries? Injury 2013; 44:1502-6. [PMID: 23481316 DOI: 10.1016/j.injury.2013.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2011] [Revised: 12/30/2012] [Accepted: 02/07/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Trauma remains a substantial cause of paediatric morbidity and mortality. Femur fractures are common in children, and frequently are the result of high-energy mechanisms of injury. A complete description of missed injuries in this population has not previously been described. MATERIALS AND METHODS A retrospective chart review of patients presenting to the Alberta Children's Hospital with femoral shaft fractures was performed. Associated injuries, and injuries with delayed diagnosis were recorded. RESULTS Twenty-percent of the patients suffered at least one other injury with their femur fracture. Six-percent of injuries had a delayed diagnosis, corresponding to three-percent of the patients reviewed. CONCLUSION There is a risk of missed injuries in the paediatric patient presenting with a femoral shaft fracture. Paediatric trauma teams and paediatric orthopaedic teams must be aware of this risk to help reduce the incidence of missed injuries. A tertiary trauma survey on children with paediatric femoral shaft fractures may help diagnose missed injuries.
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Affiliation(s)
- Andrew Dodd
- Orthopedic Surgery Residency Training Program, University of Calgary, Canada.
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19
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Abstract
BACKGROUND Complex, high-energy pediatric femur diaphyseal fractures cannot be treated reliably by conventional methods: casting is not suitable for polytrauma and large children, external fixation is associated with a high rate of malalignment and refractures, elastic nails are unsuitable for unstable fractures and metaphyseal areas, and lateral trochanteric entry rigid nails cannot address proximal and distal fragments and need relatively large medullary canals. A few centers have reported that submuscular bridge plating (SBP) is associated with minimal complications, but these findings require confirmation. QUESTIONS/PURPOSES We asked whether SBP (1) reproducibly leads to union in unstable fractures with a low complication rate, (2) leads to reasonable alignment and leg length equality (3), is unaffected by age, weight, or location of fracture, and (4) is associated with no or minimal refracture after hardware removal. METHODS We retrospectively reviewed 60 fractures in 58 patients with pediatric diaphyseal femoral fractures treated with SBP from 1999 to 2011. The average age was 9 years. Forty (67%) of the fractures were unstable. Minimum followup was 2.4 months (average, 15.5 months; range, 2.4-50.6 months). RESULTS All fractures healed well and all patients returned to full activity. Two of the 58 patients (3%) had major complications leading to unplanned surgeries: one implant failure and one deep infection in an old open fracture. None of the patients developed clinically important malalignment or leg length discrepancy. Implant removal was performed in 49 patients without complications. CONCLUSIONS SBP provided reliable fixation and healing for complex pediatric femur fractures and can have a broader application in the orthopaedic community. SBP is our preferred method for unstable fractures or fractures of the proximal and distal shaft.
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20
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Heyworth BE, Hedequist DJ, Nasreddine AY, Stamoulis C, Hresko MT, Yen YM. Distal femoral valgus deformity following plate fixation of pediatric femoral shaft fractures. J Bone Joint Surg Am 2013; 95:526-33. [PMID: 23515987 DOI: 10.2106/jbjs.k.01190] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study investigated the frequency and potential risk factors associated with the development of distal femoral valgus deformity following plate fixation of diaphyseal femoral fractures in children. METHODS Records of eighty-five skeletally immature patients who underwent plate fixation of a diaphyseal femoral fracture at a tertiary-care pediatric center from January 2003 to December 2010 were reviewed. Demographic data and clinical information were analyzed. Radiographic measurement of the distance from the distal plate edge to the distal femoral physis and of the anatomic lateral distal femoral angle was performed. Development of distal femoral valgus deformity was defined as a change in the anatomic lateral distal femoral angle of ≥5° in the valgus direction. Logistic regression analysis and contingency tables were used to relate the development of distal femoral valgus deformity with retention of hardware, patient age, fracture site, plate-to-physis distance, and the location of a bend in the plate at fixation. RESULTS Midshaft fractures (45%) were more common than proximal or distal diaphyseal fractures. Intraoperatively, the plate was bent proximally or distally, or both, in 80% of the patients. Distal femoral valgus deformity of ≥5° was seen in ten patients, eight of whom had distal diaphyseal fractures. Three of the ten patients developed symptoms as a result of the distal femoral valgus deformity that required at least one unplanned additional surgical procedure. On the basis of the statistical analysis, patients with a plate-to-physis distance of ≤20 mm (relative risk= 12.77, p = 0.005) and a distal fracture (relative risk = 11.0, p < 0.001) were at a significantly higher risk of developing distal femoral valgus deformity. Although not clearly an independent factor, a distal bend was also found to be associated with distal femoral valgus deformity (p = 0.004) but was not predictive of the pathology. CONCLUSIONS Distal femoral valgus deformity occurred in 30% of patients with distal diaphyseal fractures and in 12% overall. We advocate long-term monitoring of patients with femoral plate fixation, particularly those in whom the plate is placed ≤20 mm from the distal femoral physis.
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Affiliation(s)
- Benton E Heyworth
- Department of Orthopaedic Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
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21
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Porter SE, Booker GR, Parsell DE, Weber MD, Russell GV, Woodall J, Wagner M, Neubauer T. Biomechanical analysis comparing titanium elastic nails with locked plating in two simulated pediatric femur fracture models. J Pediatr Orthop 2012; 32:587-93. [PMID: 22892620 DOI: 10.1097/bpo.0b013e31824b7500] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Increasing attention is being paid to the influences that the body habitus and weight of the pediatric patient impose upon the fixation methods for femur fractures. Of the widely accepted treatment options, little biomechanical or clinical data exist comparing flexible intramedullary nailing and locked plating. The aim of this study was to compare the mechanical stability of unstable pediatric diaphyseal femur fractures fixed with titanium flexible intramedullary nails or a titanium locking plate using a synthetic femur model. METHODS Fracture stabilization was carried out with either 4.0-mm titanium elastic nails or 16-hole 4.5-mm narrow titanium locking compression plates. Axial and rotational testing of each specimen was performed. The axial loading rate was 0.20 mm/s. The torsional loading rate was 0.1 degrees rotation per second. The axial compressive modulus was defined as the compressive stress divided by the compressive strain. The rotational stiffness was defined as the torque moment applied to the femoral head divided by the resulting rotational displacement (in radians). The yield point or load to failure of the simulated fracture constructs was recorded for each specimen. RESULTS The modulus for comminuted fractures measured during the application of axial compression was 0.657 GPa for plate constructs and 0.326 GPa for elastic nail constructs (P=0.021). The modulus for oblique fractures during axial loading treated with plate fixation or titanium elastic nails was 1.63 and 0.466 GPa, respectively (P<0.0001). The yield point for comminuted fractures occurred at an axial load of 2304.7 N (SD ± 315.77) for plate constructs and 383.6 N (SD ± 139.2) for elastic nail constructs (P<0.001). For oblique fractures, the yield load occurred at 3111.9 N (SD ± 821.9) for plate constructs and at 1367.0 N (SD ± 98.9) for elastic nail constructs (P<0.0001). CONCLUSIONS Locked plating provides a biomechanically more stable construct than elastic intramedullary nailing. Its use as part of the technique of indirect reduction and submuscular plating remain a viable alternative in the treatment of length-unstable pediatric femur fracture patterns. CLINICAL RELEVANCE : Provide biomechanical evidence supporting the use of plating techniques in the pediatric femur fracture population.
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Affiliation(s)
- Scott E Porter
- Department of Orthopaedic Surgery, Greenville Hospital System, University Medical Center, Greenville, SC 29605, USA.
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Reynolds RAK, Legakis JE, Thomas R, Slongo TF, Hunter JB, Clavert JM. Intramedullary nails for pediatric diaphyseal femur fractures in older, heavier children: early results. J Child Orthop 2012; 6:181-8. [PMID: 23814618 PMCID: PMC3400006 DOI: 10.1007/s11832-012-0404-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 04/23/2012] [Indexed: 02/03/2023] Open
Abstract
PURPOSE A common treatment for pediatric femur fractures is intramedullary nail (IMN) insertion. Elastic stable intramedullary nails (ESINs) are often used for these procedures in heavier patients, but the potential for complications and malunion is greater. We describe here a rigid IMN specifically designed for adolescents, the adolescent lateral entry femoral nail (ALFN). The purpose of this study was to compare the recovery and complications for patients treated with ESINs to those treated with the ALFN. METHODS Our study design was a retrospective cohort study. We performed a review of medical records of 22 children ages 10-17 requiring surgical fixation of a femur fracture for a 2½-year period. Patients selected for the study had traumatic diaphyseal femur fractures and were treated with ESINs without end-caps or ALFNs. Our analyses evaluated injury, surgical, and outcome information for all patients. RESULTS Twenty-two patients were eligible for inclusion and were divided into two groups according to their treatment: the ESIN group with 7 patients and the ALFN group with 15 patients. We then performed a comparison of complications and recovery for these patients. The mean time to full weight-bearing was significantly less for the ALFN group (4.1 weeks; SD, 2.2), than the ESIN group (9.4 weeks; SD 3.9). There was no statistical difference in the incidence of major or minor complications. CONCLUSIONS Older, heavier pediatric patients treated for femur fracture with ALFNs had a shorter recovery time than similar patients treated with ESINs. However, the outcomes for both groups were satisfactory.
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Affiliation(s)
- Richard A. K. Reynolds
- />Department of Orthopedics, Children’s Hospital of Michigan, Detroit Medical Center, Detroit, MI USA
| | - Julie E. Legakis
- />Department of Orthopedics, Children’s Hospital of Michigan, Detroit Medical Center, Detroit, MI USA
| | - Ronald Thomas
- />Department of Clinical Pharmacology, Children’s Hospital of Michigan, Detroit Medical Center, Detroit, MI USA
| | - Theddy F. Slongo
- />Department of Pediatric Surgery, University Children’s Hospital, Bern, Switzerland
| | - James B. Hunter
- />Queen’s Medical Centre, Nottingham University Hospital, Nottingham, UK
| | - Jean-Michel Clavert
- />Centre Hospitalier Hautepierre, Service de Chirurgie Infantile, Strasbourg, France
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Abstract
Obesity is a rapidly expanding health problem in children and adolescents and is the most prevalent nutritional problem for children in the United States. Some believe that obesity has become a major epidemic in American children, with the prevalence having more than doubled since 1980. This epidemic has led to a near-doubling in hospitalizations with a diagnosis of obesity between 1999 and 2005 and an increase in costs from $125.9 million to $237.6 million between 2001 and 2005. This article describes some of the orthopaedic conditions commonly encountered in overweight/obese children and adolescents, classically infantile and adolescent tibia vara and slipped capital femoral epiphysis. Also discussed are genu valgum, which has been associated with obesity, and other difficulties encountered in providing orthopaedic care to obese children.
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Affiliation(s)
- F Keith Gettys
- Department of Orthopaedic Surgery, Carolinas Medical Center, Charlotte, NC 28232, USA
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Abstract
Despite many treatment options, the treatment of metaphyseal pediatric femoral fractures remains to be controversial. Fixation of most metaphyseal femoral fractures in older children is difficult to perform. Recently, bridging fixation of such fractures by submuscular plating has become popular. Plate precontouring as close as possible to anatomic bony structure is important, as the femur will subsequently reduce to the contour of the plate with screw placement. Our technique is using plates that are anatomically precontoured to a cadaver adolescent femur to ensure proper postoperative alignment. In this study we evaluate the effectiveness of submuscular plating performed in our institution using this technique, in 11 patients. All fractures united with good alignment. No major complication occurred. In conclusion, submuscular plating of adolescent femoral fractures with precontoured plates is an effective, predictable, and safe procedure.
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Nascimento FP, Santili C, Akkari M, Waisberg G, Reis Braga SD, de Barros Fucs PMM. Short hospitalization period with elastic stable intramedullary nails in the treatment of femoral shaft fractures in school children. J Child Orthop 2010; 4:53-60. [PMID: 21286257 PMCID: PMC2811676 DOI: 10.1007/s11832-009-0227-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Accepted: 12/01/2009] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To evaluate the safety and period of hospitalization of the treatment of femoral shaft fractures with titanium elastic nails (TEN) in the age range 5 to 14 years. The hypothesis was that TEN might be a low-cost treatment, with good clinical results and short length of hospitalization. METHODS Thirty children with femur fractures were surgically treated with TEN. RESULTS The patients spent an average of 9.4 days in hospital. The average period for the healing process was 7.7 weeks. Partial weight bearing was permitted 3.3 weeks after surgery. The incidence of overgrowth was 60%, with an average of 0.40 cm. CONCLUSIONS The surgical method brings few complications and results in good limb alignment, with a short period of hospitalization and early return to daily activities and school.
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Affiliation(s)
- Fabiano Prata Nascimento
- />Pediatrics Division, Department of Orthopaedics and Traumatology, Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo (SCMSP), São Paulo, Brazil , />Rua Barão do Rio Branco 450, casa 15, Vila Assunção, Santo André, SP 09181-610 Brazil
| | - Cláudio Santili
- />Pediatrics Division, Department of Orthopaedics and Traumatology, Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo (SCMSP), São Paulo, Brazil
| | - Miguel Akkari
- />Pediatrics Division, Department of Orthopaedics and Traumatology, Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo (SCMSP), São Paulo, Brazil
| | - Gilberto Waisberg
- />Pediatrics Division, Department of Orthopaedics and Traumatology, Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo (SCMSP), São Paulo, Brazil
| | - Susana dos Reis Braga
- />Pediatrics Division, Department of Orthopaedics and Traumatology, Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo (SCMSP), São Paulo, Brazil
| | - Patrícia Maria Moraes de Barros Fucs
- />Pediatrics Division, Department of Orthopaedics and Traumatology, Faculdade de Ciências Médicas, Santa Casa de Misericórdia de São Paulo (SCMSP), São Paulo, Brazil
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Skeletal versus skin traction before definitive management of pediatric femur fractures: a comparison of patient narcotic requirements. J Pediatr Orthop 2009; 29:609-11. [PMID: 19700992 DOI: 10.1097/bpo.0b013e3181b2f728] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pediatric patients with femoral shaft fractures are often placed in traction as a temporizing measure before definitive management. The purpose of our study was to compare narcotic use in pediatric patients with isolated femoral shaft fractures that were initially treated with skeletal traction with similar patients that were initially treated with skin traction. The hypothesis was that narcotic use would not be significantly different between the groups. METHODS Chart review at 2 institutions was carried out to identify pediatric patients with isolated femoral shaft fractures treated with either skeletal traction or skin traction. The patients' age, weight, and the amount and duration of narcotic use were recorded. A 2-sample t test was used for the comparison. RESULTS Fifty-one patients were treated with skin traction and 24 patients were treated with skeletal traction. Patients in the skeletal traction group used more pain medication (0.0177 mg/kg/h in traction) than those in the skin traction group (0.0137 mg/kg/h in traction), but this was not statistically significant (P=0.1031). CONCLUSIONS The findings support our hypothesis that the amount of narcotics used between the skeletal traction group and skin traction group would not be significantly different. In using narcotic requirement as a gross measure of patient comfort while in traction, it seems there may be no benefit to the patient to have invasive skeletal traction while awaiting definitive management of their fracture. LEVEL OF EVIDENCE Retrospective comparative study, level III.
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