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de Marco G, Valaikaite R, Chargui M, Coulin B, Vazquez O, Tabard-Fougère A, Steiger CN, Dayer R, Ceroni D. Femoral fractures and abuse in children under 36 months old: a Swiss case series. J Pediatr Orthop B 2024; 33:452-461. [PMID: 37909866 PMCID: PMC11288394 DOI: 10.1097/bpb.0000000000001140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 09/17/2023] [Indexed: 11/03/2023]
Abstract
Abuse should be suspected in infant femoral fractures without significant trauma, especially if the child is non-ambulatory. Review the epidemiological and radiological characteristics of femoral fractures in children under 36 months old to identify those potentially related to child abuse. Cases involving 102 patients presenting with 103 femoral fractures between January 1990 and December 2020 were investigated, paying close attention to mechanisms of injury, fracture patterns, and their possible relations to child abuse. The annual incidence of femoral fractures in patients under 36 months old was estimated at 24.6 per 100 000; the incidence in infants under 13 months was significantly higher than among children between 13 and 36 months old. Most infants under 13 months suffered from transverse or oblique metaphyseal/diaphyseal fractures (93.2%), whereas 67.8% of older children presented with spiral shaft fractures. Data confirmed child abuse in 4.9% of all patients (one with bilateral fractures); femoral fractures were incompatible with their reported mechanisms of injury in 31 patients (30.4%), whereas 12 fractures (11.8%) occurred in unexplained circumstances. More than 50% of femoral fractures occurred with low-energy trauma. The difference in patterns according to patients' ages suggested different mechanisms of trauma in ambulatory and non-ambulatory infants. Confirmed abuses and unclear or inconsistent mechanisms of trauma, raised potential total child abuse cases to 47.1% of our cohort. Level of evidence: Level IV.
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Affiliation(s)
- Giacomo de Marco
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Raimonda Valaikaite
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Moez Chargui
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Benoit Coulin
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Oscar Vazquez
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Anne Tabard-Fougère
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Christina N. Steiger
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Romain Dayer
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Dimitri Ceroni
- Service of Pediatric Orthopedics, The Children’s Hospital, Geneva University Hospitals, Switzerland
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Ina J, Dumaine AM, Flanagan C, Haase L, Moore R, Rimnac C, Gilmore A. Findings Associated With Nonaccidental Trauma in Children With Isolated Femoral Diaphyseal Fractures. J Pediatr Orthop 2024; 44:e717-e721. [PMID: 38813812 DOI: 10.1097/bpo.0000000000002740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Pediatric patients with isolated femoral diaphyseal fractures are difficult to assess for nonaccidental trauma (NAT). The purpose of this study was to determine (1) if there are any demographic features of isolated femoral diaphyseal fractures associated with suspected NAT and (2) if there are clinical signs associated with isolated femoral diaphyseal fractures associated with suspected NAT. METHODS All patients with femoral diaphyseal fractures from January 2010 to June 2018 were reviewed. We included patients younger than 4 years old with isolated femoral diaphyseal fractures. We excluded patients 4 years old and older, polytraumas, motor vehicle collisions, and patients with altered bone biology. Diagnosis of suspected NAT was determined by review of a documented social work assessment. We recorded fracture characteristics including location along femur as well as fracture pattern and presence of associated findings on NAT workup including the presence of retinal hemorrhage, subdural hematoma, evidence of prior fracture, or cutaneous lesions. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these associated findings were calculated. RESULTS Totally, 144 patients met the inclusion criteria. Social work was consulted on 50 patients (35%). Suspected NAT was diagnosed in 27 patients (19%). The average age of patients with suspected NAT was 0.82 and 2.25 years in patients without NAT ( P <0.01). The rate and type of skin lesions present on exam were not different between the 2 groups. Patients with suspected NAT had no findings of retinal hemorrhage or subdural hematoma, but 5 of 27 patients (19%) had evidence of prior fracture on skeletal survey. The sensitivities of retinal hemorrhage, subdural, and skeletal survey were 0%, 0%, and 19% and the specificities of all were 100%. The NPVs were 39%, 27%, and 63%, respectively. The PPV of skeletal survey was 100%. Since there were no patients in this study with positive findings of retinal hemorrhage or subdural hematoma, the PPV for these could not be assessed. CONCLUSIONS In the current study, signs of NAT such as skin lesions, retinal hemorrhage, subdural hematoma, and evidence of prior fracture on skeletal survey may not be helpful to diagnosis suspected NAT in patients with an isolated femoral diaphyseal fracture. LEVEL OF EVIDENCE Level III-diagnostic study.
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Affiliation(s)
- Jason Ina
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center
| | - Anne M Dumaine
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center
| | - Christopher Flanagan
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center
| | - Lucas Haase
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center
| | - Rebecca Moore
- Department of Mechanical and Aerospace Engineering, Case Western Reserve University, Cleveland, OH
| | - Clare Rimnac
- Department of Mechanical and Aerospace Engineering, Case Western Reserve University, Cleveland, OH
| | - Allison Gilmore
- Department of Pediatric Orthopaedics, Rainbow Babies and Children's Hospital at University Hospitals Cleveland Medical Center
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Diaphyseal Femur Fractures in Children and Adolescents-Opportunities and Limitations of the ESIN Technique. J Clin Med 2022; 11:jcm11247345. [PMID: 36555961 PMCID: PMC9784624 DOI: 10.3390/jcm11247345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022] Open
Abstract
Background: Elastic stable intramedullary nailing (ESIN) is the gold standard for non-overweight children aged 6−12 years. However, the complication rate using elastic stable intramedullary nailing is considerably high. Nevertheless, the question arises of whether the indication for elastic stable intramedullary nailing therapy can be extended and which factors must be taken into account when determining the indication. Methods: A retrospective chart review of patients <18 years admitted with diaphyseal femur fracture at a Level I Trauma Center in Germany between 2005 and 2017 was performed. In total, 118 patients were included. For the classification of femur fractures in children, the AO Pediatric Comprehensive Classification of Long-Bone Fractures (AO-PCCF) was applied. Results: Simple oblique fractures (32-D/5.1) occurred in most of the patients. Patients with simple oblique fractures were significantly younger compared to patients with simple transverse (32-D/4.1) or multifragmentary (32-D/5.2) fracture type according to the AO Pediatric Comprehensive Classification of Long-Bone Fractures. Most patients were treated with elastic stable intramedullary nailing (68 patients, 58%). Although children treated with elastic stable intramedullary nailing were older than those treated conservatively (25%, n = 29, mean age 1.5, median age 1.0), the children in the elastic stable intramedullary nailing group were comparatively young (range 1−12 years, mean age 5.4, median age 5). A total of 32 children below the age of 6 years were treated with elastic stable intramedullary nailing. Complications were more frequent in patients with overhead extension (50%) compared to conservative treatment with a spica cast (17%) or elastic stable intramedullary nailing (15%). Conclusions: Elastic stable intramedullary nailing therapy was associated with a low complication rate and was, therefore, a safe and frequently used treatment strategy in diaphyseal femur fractures with satisfactory results, even though the age groups were expanded in favor of younger patients.
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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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Cintean R, Eickhoff A, Pankratz C, Strauss B, Gebhard F, Schütze K. ESIN in femur fractures in children under 3: is it safe? Eur J Trauma Emerg Surg 2022; 48:3401-3407. [PMID: 35394142 PMCID: PMC9532282 DOI: 10.1007/s00068-022-01965-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 03/23/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pediatric femur fractures are a major trauma in children. Different treatment algorithms have been developed but indications for surgical treatment, especially in very young patients, are still controversial. Literature recommends surgical stabilization with elastic-stable intramedullary nailing (ESIN) starting at the age of 3 and non-operative treatment in younger patients. This study sought to present the outcome of patients younger than 3 years of age treated with ESIN for femur fractures. MATERIALS AND METHODS Inclusion criteria were patients younger than 3 treated with ESIN in femur fractures. Patient demographics, fracture characteristics, mechanism of injury, outcomes and complications were recorded using charts and X-rays. Primary outcome measures were time to mobility, fracture consolidation and surgical-related complications. RESULTS Between 2010 and 2020, 159 patients were treated with ESIN in femur fractures in our institution. A total of 30 patients met the criteria. The mean age was 2.1 ± 0.7 years (13 months-2.9 years). Most common mechanism was fall from standing height (60%). Other mechanisms were motor vehicle accidents as a pedestrian (10%) or as a passenger (10%) as well as direct blow trauma (20%). Femoral shaft fracture was the most common injury (80%). 5 subtrochanteric and one distal metaphyseal femur fractures were found. Mean length of stay was 2.0 ± 1.3 days. Radiographic controls were performed on day 1, 14 and 6 weeks after surgery if not otherwise specified or if complications occurred. 4.6 ± 1.2 (n 2-7) X-rays were performed on average after surgery. First radiographic consolidation signs were seen after 2.4 ± 0.6 weeks. Only one child showed surgical-related complication with a leg length discrepancy of 1 cm. In 10% of the patients, shortening after surgery of 1.7 ± 1.4 mm (0.3-3.1 mm) occurred. One child initially treated with traction therapy showed skin irritations and was operated with ESIN. No non-union or ESIN-related complications were found. Mean follow-up was 5.1 ± 4.4 months (4-24 months). First independent mobilization was seen at an average of 3.4 ± 1.1 weeks (2-6 weeks) after surgery. Implant removal was performed after 3.2 ± 1.3 months (2-8 months). No refracture after implant removal occurred. CONCLUSION Early results with ESIN show a reasonable and safe treatment option for femur fractures in toddlers and young children under the age of 3 with easy postoperative care, fast fracture union and early independent mobilization.
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Affiliation(s)
- Raffael Cintean
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Alexander Eickhoff
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Carlos Pankratz
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Beatrice Strauss
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Florian Gebhard
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Konrad Schütze
- Department of Trauma-, Hand-, and Reconstructive Surgery, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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Yuan H, Yu H, Zhu Y, Xiang L, Wang H. Effect of Age on the Patterns of Traumatic Femoral Fractures: Seven Years of Experience at a Regional Tertiary Hospital. Orthop Surg 2022; 14:2132-2140. [PMID: 35929600 PMCID: PMC9483057 DOI: 10.1111/os.13410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/11/2022] [Accepted: 06/26/2022] [Indexed: 11/29/2022] Open
Abstract
Objective Femoral fractures are a common cause of mortality and functional loss, mainly among older people, and there are few studies about the age in relation to traumatic femoral fractures. The aim of this study was to investigate the effect of age on the patterns of traumatic femoral fractures in patients presenting to our regional tertiary hospital. Methods The records of 2020 patients who presented with traumatic femoral fractures between 2013 and 2019 were retrospectively reviewed. The patients' clinical and radiographic records were reviewed. Univariate and multivariable logistic regression were used to identify independent risk factors for associated injuries and complications. Results The patients were divided into a child group (CH group, n = 342) aged under 18 years, a young adult group (YA group, n = 484) aged 18–60 years, and an older people group (OP group, n = 1194) aged 60 years and over. There were significant differences among the three groups in several indexes, such as sex ratio (χ2 = 301.699, p < 0.001), osteoporosis (χ2 = 375.463, p < 0.001), injury time of day (χ2 = 114.913, p < 0.001), injury cause (χ2 = 748.187, p < 0.001), injury location (χ2 = 490.153, p < 0.001), fracture side (χ2 = 57.000, p < 0.001), fracture site (χ2 = 806.650, p < 0.001), associated injuries (χ2 = 322.921, p < 0.001), coma after injury (χ2 = 147.814, p < 0.001), non‐surgery‐related complications (χ2 = 7.895, p = 0.019), and surgery‐related complications (χ2 = 82.186, p < 0.001). The YA group had a significantly higher percentage of patients with surgery‐related complications than the OP group. The OP group had a higher frequency of non‐surgery‐related complications than the YA group and CH group. The most common non‐surgery‐related complications were pneumonia (7.1%) in the OP group and deep venous thrombosis (6.4%) in the YA group. Multivariable logistic regression showed that young adults, high‐energy injury, outdoors, coma after injury, and fracture sites except for the proximal region were independent risk factors for associated injuries. Older age, male, and fracture site except for the proximal region were independent risk factors for complications. Conclusions Traumatic femoral fractures are mostly the result of low‐energy trauma and predominantly affect the proximal site of the femur among older people. A higher rate of shaft fractures, fractures occurring outdoors, and associated injuries were observed among young adults and children than among older people.
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Affiliation(s)
- Hong Yuan
- Department of Orthopaedics, General Hospital of Northern Theater Command of Chinese PLA, Shenyang, China
| | - Hailong Yu
- Department of Orthopaedics, General Hospital of Northern Theater Command of Chinese PLA, Shenyang, China
| | - Yunpeng Zhu
- Department of Orthopedics, Hong Hui Hospital, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Liangbi Xiang
- Department of Orthopaedics, General Hospital of Northern Theater Command of Chinese PLA, Shenyang, China
| | - Hongwei Wang
- Department of Orthopaedics, General Hospital of Northern Theater Command of Chinese PLA, Shenyang, China
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Macha AP, Temu R, Olotu F, Seth NP, Massawe HL. Epidemiology and associated injuries in paediatric diaphyseal femur fractures treated at a limited resource zonal referral hospital in northern Tanzania. BMC Musculoskelet Disord 2022; 23:360. [PMID: 35436903 PMCID: PMC9017012 DOI: 10.1186/s12891-022-05320-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/06/2022] [Indexed: 11/24/2022] Open
Abstract
Background Diaphyseal femur fractures contribute up to 40% of paediatric orthopaedic admissions with the World Health Organisation data showing youth are particularly vulnerable and road traffic injuries are the leading cause of death for children and young adults. Different mechanisms results to these injuries and they vary with age and geographical location of the patient. Understanding the incidence, mechanism and pattern of these injuries allows planning for preventive measures and treatment to meet modern day patient demands, generation of appropriate and timely protocols with minimum social and economic burden to the patient and family. Objectives and methods A hospital based cross sectional study was conducted using the orthopaedic department patient registry among children aged under 18 years admitted from 2014—2018. Our research question was to determine the epidemiology of diaphyseal femur fractures and coexisting associated injuries among admitted paediatric orthopaedic patients. Patient files were reviewed from the medical records department and a data collecting sheet was used to record demographics and injury data. Odds ratios with 95% confidence intervals for associated injuries in paediatric diaphyseal femur fractures were estimated using multivariable logistic regression model. Results We found the prevalence of diaphyseal femur fracture among paediatric orthopaedic admissions was 18% with the majority 111 (68.5%) being males. The leading injury mechanism was a fall (57.4%) followed by road traffic injuries (35.8%) out of which 48.3% resulted from pedestrian vs motorcycle accidents. Traumatic brain injury (TBI) was the most common associated injuries accounting for 69% of these injuries with the majority 79% occurring in patients aged 6 years and older. With age specific analysis, children in 6–12 years and 13–18 years age groups, had 8 and 11 times higher odds for associated injuries (OR 8.25, 95% CI, 1.04—65.31) p = 0.046 and (OR 10.54, 95% CI, 1.26—88.31) p = 0.031 respectively compared to those younger ≤ 2 years. Road traffic related injuries had 17 times higher odds of associated injuries when compared to fall (OR 16.73, 95% CI, 6.28—44.57) p < 0.001. 112 (69.1%) of femur fractures were treated by non-operative method out of this 90 (55.6%) by traction with delayed Spica application. The overall mean duration of hospital stay was 18.5 ± 11 days. Conclusion Pedestrian vs motorcycle injuries was the leading specific cause of paediatric diaphyseal femur fractures with TBI being the common associated injury. Non-operative management was the most utilized treatment plan and contributed to ten times higher odds for a longer duration of hospital stay. Initiatives to insure children safety on roads should be strengthened in order to reduce/eliminate this burden. Application and practice of current evidence based clinical guidelines and recommendations is paramount for timely and appropriate treatment of these injuries. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05320-x.
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Affiliation(s)
- Albert P Macha
- Department of Orthopaedic and Trauma, Muhimbili Orthopaedic Institute, P.O.Box 38645, Dar es Salaam, Tanzania.
| | - Rogers Temu
- Department of Orthopaedic Surgery, Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Frank Olotu
- Department of Orthopaedic Surgery, Kilimanjaro Christian Medical Centre, Moshi, Kilimanjaro, Tanzania
| | - Neil P Seth
- Department of Orthopaedic Surgery, Pennsylvania Hospital, University of Pennsylvania, Philadelphia, USA
| | - Honest L Massawe
- Department of Orthopaedic Surgery, Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
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Flexible Intramedullary Nail Versus Submuscular Locked Plate with the Cluster Technique in Pediatric Femoral Shaft Fractures Fixation. Indian J Orthop 2021; 56:580-586. [PMID: 35342514 PMCID: PMC8921348 DOI: 10.1007/s43465-021-00571-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/11/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE OF THE STUDY The aim of this study is the comparison between the flexible intramedullary nail and submuscular Locked Plate with the cluster technique in fixation of pediatric femoral shaft fractures at the age group between 6 and 12 years old with simple diaphyseal closed or Gustilo open grade I fractures. METHODS Fifty children aged 6-12 years with femoral fractures were enrolled in this study. The children were randomly assigned equally to the two groups for fractures fixation. The follow-up period was 1 year. A comparison of various parameters and outcomes between both groups was documented. RESULTS No significant differences were detected between both groups regarding the age, gender, affected side, mechanisms of fracture, or fracture classifications. The operative time and radiation time were longer in the plating group, while the amount of blood loss was lesser in the nail group. The patients treated with plating had better results concerning knee range of motion, weight-bearing, malalignment, and length discrepancy, with fewer complications and better functional outcomes. CONCLUSION The result of the present study supports the use of submuscular locked plate with cluster technique in the treatment of studied fractures over flexible IMN.
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Szabo E, Rimnac C. Biomechanics of immature human cortical bone: A systematic review. J Mech Behav Biomed Mater 2021; 125:104889. [PMID: 34736022 DOI: 10.1016/j.jmbbm.2021.104889] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/10/2021] [Accepted: 10/06/2021] [Indexed: 12/31/2022]
Abstract
The whole bone geometry, microstructure, and mechanical properties of mature human bone are widely reported; however, immature bone (0-18 years) has not been similarly robustly characterized. There is an interest in analyzing and predicting the mechanical loading conditions associated with long bone diaphyseal fractures attributed to trauma in children. Thus, understanding the mechanical properties of immature bone in a temporal reference frame is an essential first step to understand diaphyseal fractures of pediatric long bones. The purpose of this systematic review was to ask, what is the state of knowledge regarding the 1) evolution of whole bone geometry and microstructure of immature pediatric bone as a function of maturation and 2) cortical bone density and experimental quasi-static mechanical properties at the tissue level in the diaphyseal region of immature pediatric long bones? The systematic search yielded 36 studies of the whole bone geometry, microstructure, and mechanical properties of immature pediatric long bones. The elastic modulus, yield stress, and ultimate stress were shown to generally increase with maturation, whereas the yield strain was approximately invariant; however, the specific year-to-year progression of these properties could not be characterized from the limited studies available. The results of this systematic search indicate there is a dearth of knowledge associated with the biomechanics of cortical bone from immature pediatric long bones; it also provides a basis for computational studies of immature human long bones. Additional biomechanical studies of immature human bone are necessary to develop a robust catalogue, which can be used in broad applications to understand fracture mechanics, bone pathologies, and athletic injury in the pediatric setting.
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Affiliation(s)
- Emily Szabo
- Case Western Reserve University, Department of Mechanical and Aerospace Engineering, 2123 Martin Luther King Jr Dr, Cleveland, OH, 44106, USA.
| | - Clare Rimnac
- Case Western Reserve University, Department of Mechanical and Aerospace Engineering, 2123 Martin Luther King Jr Dr, Cleveland, OH, 44106, USA.
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Efficacy of fascia iliaca nerve block in daily routine for children with femoral fractures in a pediatric emergency department. Arch Pediatr 2021; 28:544-547. [PMID: 34593294 DOI: 10.1016/j.arcped.2021.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 04/13/2021] [Accepted: 08/09/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVES We aimed to evaluate the efficacy of fascia iliaca nerve block (FINB), routinely used for children with femoral fractures, in a pediatric emergency department (PED). METHODS This retrospective, single-center, observational study examined FINB using ropivacaine and a 1% lidocaine hydrochloride solution, in all patients under 18 years of age admitted with a femoral fracture from January 2012 to December 2016. Pain was assessed using two validated pediatric pain scales: EVENDOL or a visual analog scale. A level of ≥ 4 on either scale indicates the need for an analgesic. The primary outcome was the percentage of patients who were pain free after the FINB procedure defined by a pain score of < 4. Secondary outcomes were the time spent between PED admission and FINB, the need of additional analgesics, side effects, and the success rate of FINB. RESULTS Of 161 patients screened, 144 were included. The median age was 3.2 years (range 2 months to 16 years) and 74% were boys. The number of children determined to be pain free (pain score < 4) increased from 36 (25%) before the FINB to 123 (85%) after the FINB (absolute risk difference 60%, 95% CI: 51%-70%). Overall, 21 children (15%) required a second analgesic after the FINB. CONCLUSION The routine use of FINB with ropivacaine and lidocaine by pediatric ED physicians provided effective pain relief for children admitted for a femoral fracture in the emergency department. Our data support the efficiency and feasibility of FINB for the antalgic management of children with femoral fracture.
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Miyamoto S, Otsuka M, Hasue F, Fujiyoshi T, Kamiya K, Kiuchi H, Odagiri T, Tanaka T, Nakamura J, Orita S, Ohtori S. Associated injury complicated by pediatric lower limb shaft fractures and clinical efficacy of flexible stainless-steel intramedullary nailing in children less than 15 years old. Orthop Rev (Pavia) 2021; 13:8008. [PMID: 33897986 PMCID: PMC8054656 DOI: 10.4081/or.2021.8008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/05/2021] [Indexed: 11/23/2022] Open
Abstract
Although pediatric lower limb shaft fractures are common, little is known about associated injuries. The purpose of this study was to examine associated injuries complicated by pediatric lower limb shaft fractures and the efficacy of surgical treatment using a flexible stainless-steel intramedullary Ender nail in children less than 15 years old. This is a retrospective review of 29 children younger than 15 years old who were diagnosed with femoral or tibial shaft fractures and treated using Ender nails from 2005 to 2016. Baseline data, etiology, associated injuries, fracture site and patterns, operative and post-operative assessment were evaluated. The average age of the patients was 9.0 years, and mean follow-up was 18.2 months. Eleven patients (79%) had associated injury. At the final follow up, six patients (43%) sustained complications associated with the insertion area of the nail. There was no evidence of deep infection or nonunion at either fracture site. The clinical results were excellent in 10 (67%) fractures, and good in 5 (33%) fractures, based on the modified Flynn criteria. Almost all patients with a femoral fracture had an associated injury including abdominal visceral injury, cerebral contusion or other fractures. This study indicated good clinical and functional outcomes. On the other hand, the minor complications rate was high. Nevertheless, elastic stable intramedullary nailing recently has become available in Japan, and a prospective and comparative study is needed.
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Affiliation(s)
| | | | - Fumio Hasue
- Kimitsu Central Hospital, Kisarazu City, Chiba
| | | | | | | | | | | | - Junichi Nakamura
- Graduate School of Medicine, Chiba University, Chiba City, Chiba
| | - Sumihisa Orita
- Center for Advanced Joint Function and Reconstructive Spine Surgery Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Seiji Ohtori
- Graduate School of Medicine, Chiba University, Chiba City, Chiba
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Xing H, Wu Q, Lan S, Wang C, Ye J, Ye F, Huang S. Ipsilateral femoral neck and shaft fracture in children: Two case reports. Medicine (Baltimore) 2021; 100:e23616. [PMID: 33530163 PMCID: PMC7850742 DOI: 10.1097/md.0000000000023616] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 11/10/2020] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Pediatric femoral shaft combined with ipsilateral femoral neck fractures are very rare but challenging injuries fraught with the development of avascular necrosis, coxa vara, and leg length discrepancy. Majority of the previous reports indicated the neck femur fracture was fixed with cannulated screws or/and pins, femoral shaft fracture was stabilized with a plate and screws. However, we used cannulated screws combined with elastic stable intramedullary nails to minimally invasive procedures treat this type of injury and achieved good follow-up results. PATIENT CONCERNS A 7-year-old boy (Case 1) was hospitalized due to a traffic accident resulting in swelling and deformity of the right thigh accompanied by limited mobility of hip and knee. A 5-year-old male child (Case 2) presented with pain and swelling in the bilateral lower limb after fall from approximately 12 feet. DIAGNOSES Physical examination, X-ray film, and computed tomography were performed. Both patients were diagnosed with ipsilateral femoral neck and shaft fracture. INTERVENTIONS The fractures were reduced closed by image-intensifier imaging. Two partially threaded cancellous screws were used to fix femoral neck fracture, and elastic intramedullary nails were performed to stable the femoral shaft fracture. Postoperatively, the patients were immobilized in a one-and-a-half hip spica cast for six weeks. The internal fixations were removed after one year. OUTCOMES Case one was follow-up at 14 months and the other one was followed up for 3 years. And at the last follow-up showed a normal and painless hip function. No clinical complications were found during follow-up visit, including head penetration, implant failure, fracture nonunion, avascular necrosis and hip varus deformity. LESSONS Clinician should carefully check and read relevant imaging data to avoid missed diagnosis. And the internal fixation method described in this paper may be more minimally invasive.
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Bakhsh K, Zimri FK, Mohammad E, Atiq-Ur-Rehman, Saaiq M. Presentation and outcome of femoral infected non-unions in children and adolescents. Pak J Med Sci 2021; 37:201-205. [PMID: 33437277 PMCID: PMC7794135 DOI: 10.12669/pjms.37.1.3354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/25/2020] [Accepted: 10/15/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To document the presentation of infected non-unions of femur in pediatric and adolescent population and evaluate the outcome of segmental bone transport with the Ilizarov method. METHODS This prospective case series study was carried out over a period of five years, from January 01, 2015 to December 31, 2019. The study included all children and adolescent patients who presented with femoral infected non unions. The study excluded patients above the age of 16 years and those who had pathological fractures secondary to bone pathologies such as cysts, tumors or metabolic bone diseases. RESULTS Out of 31 patients, 27(87.09%) were males and 4(12.90%) were females. The mean age was 13.48±1.98 years. The underlying mechanisms that lead to the causation of fractures included road traffic accidents (n=23;74.19%), fall from height (n=7;22.58%) and firearm injuries (n=1;3.22%). The bone gaps ranged from 3-5 cm with a mean of 4.00± 0.856 cm. Bone union was achieved among 28(90.32%) patients. Infection was eradicated among 27(87.09%) patients whereas the remaining patients continued to suffer persistent infection. The most common complications included pin tract inflammation/ infection among (n=31;100%) patients and stiffness of knee joint among (n=19;61.29%) patients. CONCLUSION Majority of the patients were males, aged 9-16 years. Road traffic accidents were the commonest cause of the fractures. The Ilizarov method of segmental bone transport was effective in treating the majority of infected non-unions.
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Affiliation(s)
- Karim Bakhsh
- Dr. Karim Bakhsh, FCPS. Department of Orthopedics, Bolan Medical Complex Hospital, Quetta, Pakistan
| | - Faridullah Khan Zimri
- Dr. Faridullah Khan Zimri, FCPS. Department of Orthopedics, NIRM, Islamabad, Pakistan
| | - Eid Mohammad
- Dr. Eid Mohammad, FCPS. Department of Orthopedics, Bolan Medical Complex Hospital, Quetta, Pakistan
| | - Atiq-Ur-Rehman
- Dr. Atiq-Ur-Rehman, FCPS. Department of Orthopedics, Bolan Medical Complex Hospital, Quetta, Pakistan
| | - Muhammad Saaiq
- Dr. Muhammad Saaiq, FCPS. Department of Plastic Surgery, NIRM, Islamabad, Pakistan
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Engström Z, Wolf O, Hailer YD. Epidemiology of pediatric femur fractures in children: the Swedish Fracture Register. BMC Musculoskelet Disord 2020; 21:796. [PMID: 33261600 PMCID: PMC7706285 DOI: 10.1186/s12891-020-03796-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/16/2020] [Indexed: 11/29/2022] Open
Abstract
Background Although femur fractures in children are rare, they are the most common fractures in need of hospitalization. We sought to describe the epidemiology and treatment of pediatric femur fractures recorded in the Swedish Fracture Register (SFR). We also studied the relationship between femur fractures, age, sex, fracture pattern, injury mechanism, seasonal variation and treatment. Methods This nationwide observational register study was based on the pediatric part of the SFR. We included all patients < 16 years of age who were registered in the SFR from 2015 to 2018. Results Of the 709 femur fractures, 454 (64%) occurred in boys. Sixty-two of these fractures were proximal (9%), 453 shaft (64%) and 194 distal (27%). A bimodal age distribution peak was observed in boys aged 2–3 and 16–19 years. In contrast, the age distribution among girls was evenly distributed. Younger children were mainly injured by a fall, whereas older children sustained their fracture because of traffic accidents. Non-surgical treatment prevailed among younger children; however, prevalence of surgical treatment increased with age. Conclusions We found a lower ratio between boys and girls (1.8:1) compared to earlier studies. The bimodal age distribution was seen only in boys. Falls were the most common injury in younger children, whereas traffic-related accidents were the most common in adolescents. With age, there was a corresponding increase in surgical treatment.
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Affiliation(s)
- Zandra Engström
- Section of Orthopaedics, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - Olof Wolf
- Section of Orthopaedics, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Yasmin D Hailer
- Section of Orthopaedics, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Isolated Femoral Shaft Fracture in Wakeboarding and Review of the Literature. Case Rep Orthop 2020; 2020:8841395. [PMID: 33014493 PMCID: PMC7520687 DOI: 10.1155/2020/8841395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/24/2020] [Accepted: 08/31/2020] [Indexed: 11/17/2022] Open
Abstract
Introduction Wakeboarding is an extreme sport that has shown increasing popularity in recent years, with an estimated 2.9 million participants in 2017. Due to this trend, injuries related to this sport are likely to become more common. Isolated femoral shaft are rare; however, they occur much more frequently in youth as a result of high velocity events, such as dashboard-related injuries. Few studies have addressed injuries related to wakeboarding, and of those that have, most have reported on muscle injuries, ligament ruptures, and sprains. Due to the dearth in literature, we want to present two cases of isolated noncontact femoral shaft fractures that resulted from wakeboarding. Case Presentation. Two 28-year-old, otherwise healthy, wakeboarders-patient A, male, and patient B, female-presented to our Department of Orthopaedics and Sports Medicine with isolated femoral shaft fractures. Both were admitted due to wakeboard-related noncontact injuries, where patient A fell while performing a sit-down start during cable wakeboarding and patient B after attempting a wake-jump. Both patients were being pulled by motorboats at roughly 40 km/h. After clinical examination and radiography, left spiral (AO classification: 32-A1.2) (patient A) and right-sided bending, wedge (AO classification 32-B2.2) (patient B) isolated femoral shaft fractures were diagnosed. No concomitant injuries were reported. For treatment, long reamed locked nails were applied, while the patients were under spinal anaesthesia. Physiotherapy was prescribed postoperatively. Patient A returned to wakeboarding 155 days after the surgery, and patient B returned after approximately half a year. Conclusion This case series shows that even in noncontact sports such as wakeboarding, high-energy forces applied to the femur can cause isolated femoral shaft fractures. Despite multiple reports in various sports of stress fractures of the femur, there are few publications of direct trauma.
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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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Ulici A, Odagiu E, Haram O, Ionescu A, Sterian GA, Carp M, Tevanov I. Poor prognostic factors of femoral shaft fractures in children treated by elastic intramedullary nailing. SICOT J 2020; 6:34. [PMID: 32870156 PMCID: PMC7461699 DOI: 10.1051/sicotj/2020031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/11/2020] [Indexed: 11/14/2022] Open
Abstract
Introduction: Femoral shaft fractures in pediatric patients are treated by elastic intramedullary nailing using titanium or stainless-steel nails. The elastic stable intramedullary nailing behaves as an internal splint, promoting early mobilization. This type of treatment involves a minimally invasive approach, no damage to the growth plates, and no impairment of femoral head blood supply. Purpose: The aim of our study was to identify the negative predicting factors that might lead to an increased complication rate after elastic stable intramedullary nailing of femoral shaft fractures in children. Methods: We conducted a retrospective study on 137 patients with femoral shaft fractures treated by elastic stable intramedullary nailing. Patients’ age ranged between 4 and 17 years. We used data from the medical records of the patients to evaluate postoperative complications. Plain radiographs were analyzed to determine the fracture type, fracture location, and postoperative complications such as delayed union, angular deformities, and limb length discrepancies. Multivariate analysis was conducted to identify predictors for poor outcomes. Results: Complications occurred in 29 patients (21%) and consisted of delayed union, axial deformities, or lower limb length discrepancies. In the group of patients that suffered from complications, mechanism of injury, age, and weight were significant. They were older by an average of 5 years; half of them weighed more than 50 kg and over a half were involved in a road traffic accident. Conclusions: Elastic nailing is a successful tool to treat femoral shaft fractures. Three factors were demonstrated to influence the outcome. The mechanism of injury, age > 11 years, and weight > 50 kg are the most important and are predictors for development of complications such as delayed union or deformity.
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Affiliation(s)
- Alexandru Ulici
- Department of Pediatric Orthopedic Surgery, Emergency Hospital for Children "Grigore Alexandrescu", 30-32 Iancu de Hunedoara Blvd., 011733 Bucharest, Romania - "Carol Davila" University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, București 050474, Romania
| | - Elena Odagiu
- Department of Pediatric Orthopedic Surgery, Emergency Hospital for Children "Grigore Alexandrescu", 30-32 Iancu de Hunedoara Blvd., 011733 Bucharest, Romania
| | - Oana Haram
- Department of Pediatric Orthopedic Surgery, Emergency Hospital for Children "Grigore Alexandrescu", 30-32 Iancu de Hunedoara Blvd., 011733 Bucharest, Romania
| | - Adelina Ionescu
- Department of Pediatric Orthopedic Surgery, Emergency Hospital for Children "Grigore Alexandrescu", 30-32 Iancu de Hunedoara Blvd., 011733 Bucharest, Romania
| | - Gabriel Alin Sterian
- Department of Pediatric Orthopedic Surgery, Emergency Hospital for Children "Grigore Alexandrescu", 30-32 Iancu de Hunedoara Blvd., 011733 Bucharest, Romania - "Carol Davila" University of Medicine and Pharmacy, Bulevardul Eroii Sanitari 8, București 050474, Romania
| | - Madalina Carp
- Department of Pediatric Orthopedic Surgery, Emergency Hospital for Children "Grigore Alexandrescu", 30-32 Iancu de Hunedoara Blvd., 011733 Bucharest, Romania
| | - Iulia Tevanov
- Department of Pediatric Orthopedic Surgery, Emergency Hospital for Children "Grigore Alexandrescu", 30-32 Iancu de Hunedoara Blvd., 011733 Bucharest, Romania
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Flexible intramedullary nailing of femoral shaft fractures: closed versus open reduction. J Pediatr Orthop B 2020; 29:472-477. [PMID: 31651747 DOI: 10.1097/bpb.0000000000000685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Children's femoral shaft fractures are commonly treated with flexible intramedullary nailing after closed or open reduction, but there is little information concerning indications for open reduction. The purpose of this study was to determine radiographic and clinical features likely to lead to open reduction before flexible intramedullary nailing. Record review identified 158 femoral shaft fractures treated with flexible intramedullary nailing. In addition to patient demographics and mechanism of injury, data obtained included surgeon name, estimated blood loss, type of reduction, type and diameter of nail, type of operating table, the use of percutaneous reduction techniques or supplemental casting, time to and duration of surgery, total time in operating room, and time to union. Fracture ratios were calculated based on established radiographic protocol. Of 158 fractures, 141 were treated with closed reduction and 17 with open reduction. The anteroposterior fracture index (1.3 ± 0.4, P = 0.0007), surgeon (P = 0.002), and flattop operating table (0.05) were associated with open reduction. Smaller lateral diameter of bone at the fracture site, transverse fracture, and surgeon were all found to be independent risk factors for open reduction; patient characteristics, including age, sex, and BMI, did not seem to influence the choice of open reduction. Fractures with a lower fracture index or pattern resembling a transverse fracture rather than oblique or spiral had an increased risk of converting to an open reduction. Surgeon preference and use of flattop tables also had a significant influence on how the fracture was treated.
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Predictors for Nonaccidental Trauma in a Child With a Fracture-A National Inpatient Database Study. J Am Acad Orthop Surg 2020; 28:e164-e171. [PMID: 31192884 DOI: 10.5435/jaaos-d-18-00502] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Despite heightened awareness and multidisciplinary efforts, a predictive model to help the clinician quantify the likelihood of nonaccidental trauma (NAT) in a child presenting with a fracture does not exist. The purpose of this study was to develop an evidence-based likelihood of NAT in a child presenting with a fracture. METHODS Using the 2012 Kids' Inpatient Database, we identified all available pediatric inpatients admitted with an extremity or spine fracture. Children with a fracture were subcategorized based on the diagnosis of NAT. Multivariate analysis using multiple logistic regression was used to generate odds ratios and create a predictive model for the probability of NAT in a child with a fracture. RESULTS Of the 57,183 pediatric fracture cases, 881 (1.54%) had a concurrent diagnosis of NAT. Of these children, those presenting with multiple fractures had the highest rate of NAT (2.8%). The overall mortality rate in patients presenting with fractures and abuse was 1.8%, which was twice as high as patients without abuse (odds ratio [OR] = 2.0). Based on multivariate analysis, younger age (OR = 0.5), black race (OR = 1.7), intracranial injury (OR = 3.7), concomitant rib fracture (OR = 7.2), and burns (OR = 8.3) were positive predictors of NAT in a child with a fracture. A weighted equation using regression coefficients was generated and plotted on a receiver operative characteristic curve, demonstrating excellent correlation and probability of NAT (area under curve = 0.962). (Equation - ln (P/(1 - P)) = -1.79 - 0.65 (age in years) + 0.51 (black race) + 1.97 (rib fracture) + 1.31 (intracranial injury) + 2.12 (burn)). CONCLUSION Using a large, national inpatient database, we identified an overall prevalence of 1.54% of NAT in children admitted to the hospital with a fracture. Based on five independent predictors of NAT, we generated an estimated probability chart that can be used in the clinical workup of a child with a fracture and possible NAT. This evidence-based algorithm needs to be validated in clinical practice. LEVEL OF EVIDENCE Prognostic study, Level III (case-control study).
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Mahboob A, Richmond SA, Harkins JP, Macpherson AK. Childhood unintentional injury: The impact of family income, education level, occupation status, and other measures of socioeconomic status. A systematic review. Paediatr Child Health 2019; 26:e39-e45. [PMID: 33542777 DOI: 10.1093/pch/pxz145] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/05/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction Unintentional injuries represent a substantial public health burden among children and adolescents, and previous evidence suggests that there are disparities in injury by socioeconomic status (SES). This paper reports on a systematic review of literature on injury rates among children and adolescents by measures of SES. Methods A systematic literature search was conducted using six electronic databases: MEDLINE, PsycINFO, CINAHL, HealthSTAR, EMBASE, and SportsDiscus. This review considered children ages 19 years and under and publications between 1997 and 2017-representing an update since the last systematic review examined this specific question. Fifty-four articles were summarized based on study and participant descriptions, outcome and exposure, statistical tests used, effect estimates, and overall significance. Results Most articles addressed risk factors across all injury mechanisms; however, some focused particularly on burns/scalds, road traffic injuries, falls/drowning cases, and playground/sports injuries. Other studies reported on specific injury types including traumatic dental injuries, traumatic brain injuries, and fractures. The studies were of moderate quality, with a median of 15.5 (95% confidence interval [CI]: 15.34 to 15.66) out of 19. Thirty-two studies found an inverse association between SES and childhood unintentional injury, three found a positive association while twenty were not significant or failed to report effect measures. Conclusion Given the variability in definition of the exposure (SES) and outcome (injury), the results of this review were mixed; however, the majority of studies supported a relationship between low SES and increased injury risk. Public health practice must consider SES, and other measures of health equity, in childhood injury prevention programming, and policy.
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Affiliation(s)
- Afifa Mahboob
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario
| | - Sarah A Richmond
- Health Promotion, Chronic Disease and Injury Prevention, Public Health Ontario, Toronto, Ontario.,Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
| | - Joshua P Harkins
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario
| | - Alison K Macpherson
- School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario
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Amăricăi E, Suciu O, Onofrei RR, Iacob ER, Iacob D, Popoiu CM, Negru M, Belei O, Bădițoiu L, Boia E. Static plantar pressure and functional capacity in children with femoral shaft fractures treated by titanium elastic nailing. BMC Musculoskelet Disord 2019; 20:565. [PMID: 31771558 PMCID: PMC6880557 DOI: 10.1186/s12891-019-2951-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/15/2019] [Indexed: 11/30/2022] Open
Abstract
Background Femoral shaft fractures represent common fractures of the lower limb in the paediatric population. The objectives of our study were to analyse the static plantar pressure and functional capacity in children with surgically treated unilateral femoral shaft fractures, 1 month after the metallic implant removal. Methods Our study included 24 children with unilateral femoral shaft fracture (fracture site contralateral to the dominant leg) treated by titanium elastic nailing (TEN) implants, with the removal of the implant 6 months after initial surgery. The patients were divided into two groups: Group 1 (12 patients without inpatient rehabilitation) and Group 2 (12 patients who attended inpatient rehabilitation). The patients and 12 gender and age-matched healthy controls performed plantar pressure analysis and functional capacity testing (6-min walk test: 6MWT). For patients in Group 1 and 2 the assessments were performed 1 month after the TEN implant removal. Paired t-tests were used to compare the intragroup data. A one-way ANOVA test for independent measures was performed to assess the differences for plantar pressure, and 6MWT among study groups and controls. Results All study patients had left femoral shaft fractures (affected limb). The patients and controls were all right leg dominant. In both Group 1 and Group 2 total foot loading was significantly higher on the non-affected limb compared with the affected limb. When compared to the non-affected limb, the loadings on the affected limb were significantly increased on the first and fifth metatarsal in Group 1, and on the fifth metatarsal in Group 2, with a significantly smaller heel loading. When compared with the controls we found significant differences for all pressure parameters, except for the right foot load for the rehabilitation group. Although the functional capacity values were higher in the rehabilitation group the two patients groups had significantly lower 6MWT values. Conclusions When compared to healthy controls children with surgically treated unilateral femoral shaft fractures, although assessed after 7 months, had a different weight distribution on the feet and a decreased functional capacity. A rehabilitation programme included in the management of these patients is important for regaining their functional level.
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Affiliation(s)
- Elena Amăricăi
- Department of Rehabilitation, Physical Medicine and Rheumatology, "Victor Babes" University of Medicine and Pharmacy, "Louis Țurcanu" Emergency Children's Hospital, Timisoara, Romania
| | - Oana Suciu
- Department of Rehabilitation, Physical Medicine and Rheumatology, "Victor Babes" University of Medicine and Pharmacy, "Pius Brînzeu" Emergency County Hospital, Timisoara, Romania.
| | - Roxana Ramona Onofrei
- Department of Rehabilitation, Physical Medicine and Rheumatology, "Victor Babes" University of Medicine and Pharmacy, "Pius Brînzeu" Emergency County Hospital, Timisoara, Romania
| | - Emil Radu Iacob
- Department of Paediatric Surgery, "Victor Babes" University of Medicine and Pharmacy, "Louis Țurcanu" Emergency Children's Hospital, Timisoara, Romania
| | - Daniela Iacob
- Department of Neonatology, "Victor Babes" University of Medicine and Pharmacy, "Pius Brînzeu" Emergency County Hospital, Timisoara, Romania
| | - Călin Marius Popoiu
- Department of Paediatric Surgery, "Victor Babes" University of Medicine and Pharmacy, "Louis Țurcanu" Emergency Children's Hospital, Timisoara, Romania
| | - Marius Negru
- "Louis Țurcanu" Emergency Children's Hospital, Timisoara, Romania
| | - Oana Belei
- 1st Pediatric Department, "Victor Babes" University of Medicine and Pharmacy, "Louis Țurcanu" Emergency Children's Hospital, Timisoara, Romania
| | - Luminița Bădițoiu
- Epidemiology Department, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Eugen Boia
- Department of Paediatric Surgery, "Victor Babes" University of Medicine and Pharmacy, "Louis Țurcanu" Emergency Children's Hospital, Timisoara, Romania
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Assessing the Need for Common Perioperative Laboratory Tests in Pediatric Patients With Femoral Shaft Fractures. J Pediatr Orthop 2019; 39:e456-e461. [PMID: 31022016 DOI: 10.1097/bpo.0000000000001362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Femoral shaft fractures are a common cause for hospital admission and surgery in pediatric patients, and laboratory studies are often ordered for historical concerns of excessive bleeding. Recent literature has challenged these assumptions, and unnecessary testing causes undue pain and costs in children. No previous studies have offered evidence-based recommendations for perioperative laboratories in isolated pediatric femoral shaft fractures. METHODS We retrospectively reviewed all patients presenting with femoral shaft fractures at our pediatric trauma center between 2013 and 2017. Patients with multitrauma injuries, metabolic/neuromuscular diseases, or intensive care unit stays were excluded. Necessity of laboratory tests was determined by rates of anemia, blood transfusions, specialist consultations, and delayed surgeries. Ordering patterns were recorded, with cost estimation based on Healthcare Bluebook. RESULTS We reviewed 95 patients (mean age, 7.9±4.8 y; 70 males). Treatments included elastic nails (33/95, 34.7%), reamed intramedullary nails (24/95, 25.3%), plates/screws (12/95, 12.6%), and spica casting (26/95, 27.4%). Of 32 patients with preoperative coagulation laboratories, 11 were abnormal; however none resulted in hematology consultations or procedure delays. Seventy-five patients (78.9%) and 15 patients (15.8%) had complete blood counts preoperatively and postoperative day 1, respectively. Four patients (4.2%) had hemoglobin<8 g/dL postoperatively, however, there were no perioperative blood transfusions. Of these 4, 3 underwent either reamed intramedullary nails or open reduction internal fixation with plates/screws. Twenty-six patients (27.4%) had preoperative basic metabolic panels that did not alter medical care. On the basis of our criteria, over 72% of laboratories appeared unnecessary, with a total potential cost of $8567. Over 80% of orders were from the emergency department by residents or attending physicians. CONCLUSIONS Perioperative laboratory orders may be unnecessary in most isolated pediatric femoral shaft fractures, subjecting patients to extraneous costs, and associated pain. However, laboratories may be justified based on clinical circumstances or for older patients treated with reamed nails or plates/screws. Evidence-based recommendations for perioperative laboratory orders offer the potential to improve quality and value and minimize harm in pediatric orthopaedic trauma. LEVEL OF EVIDENCE Level III-retrospective comparative study (therapeutic).
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The frequency of nonaccidental trauma in children under the age of 3 years with femur fractures: is there a better cutoff point for universal workups? J Pediatr Orthop B 2018; 27:366-368. [PMID: 28926487 DOI: 10.1097/bpb.0000000000000495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
The purpose of this study was to evaluate narrower age groups in children aged 0-4 years to determine whether guidelines should be refined when investigating femur fractures for nonaccidental trauma (NAT). This was a retrospective review of the pediatric trauma database at our level 1 pediatric trauma center. The database was examined from 2009 to present. We examined rates of NAT in the less than or equal to 12-month, 13-24-month, 25-36-month, and 37-48-month age groups. χ was used to compare rates of NAT between these groups, and P less than 0.05 was considered to be significant. Over the indicated time period, there were 138 femur fractures in children aged 0-4 years, of which 30 were determined to be NAT. The rate of NAT in the less than or equal to 12-month age group was 74.1%, accounting for 20 of the 30 NAT femur fractures. A significant difference in rates of NAT was found between the less than or equal to 12-month age group and all other age groups (P<0.00001). No significant difference in rates of NAT was found between the 13-24-month, 25-36-month, and 37-48-month age groups. Although our institution has generally felt that NAT should be universally evaluated in patients below 36 months of age with femur fractures, our data suggest that there is little justification for universally evaluating 13-36-month-old patients with femur fractures for NAT when the rates do not differ for 37-48-month-old patients. NAT does exist in femur fractures in children above 12 months of age, but it is most worrisomely high in patients of less than or equal to 12 months of age.
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Chauvin-Kimoff L, Allard-Dansereau C, Colbourne M. L’évaluation médicale des fractures en cas de soupçons de maltraitance : les nourrissons et les jeunes enfants atteints d’une lésion squelettique. Paediatr Child Health 2018. [DOI: 10.1093/pch/pxx183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Laurel Chauvin-Kimoff
- Société canadienne de pédiatrie, section de la prévention de la maltraitance d’enfants et d’adolescents, Ottawa (Ontario)
| | - Claire Allard-Dansereau
- Société canadienne de pédiatrie, section de la prévention de la maltraitance d’enfants et d’adolescents, Ottawa (Ontario)
| | - Margaret Colbourne
- Société canadienne de pédiatrie, section de la prévention de la maltraitance d’enfants et d’adolescents, Ottawa (Ontario)
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Chauvin-Kimoff L, Allard-Dansereau C, Colbourne M. The medical assessment of fractures in suspected child maltreatment: Infants and young children with skeletal injury. Paediatr Child Health 2018; 23:156-160. [PMID: 29688229 PMCID: PMC5905568 DOI: 10.1093/pch/pxx131] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Fractures are common injuries in childhood. While most fractures are caused by accidental trauma, inflicted trauma (maltreatment) is a serious and potentially unrecognized cause of fractures, particularly in infants and young children. This practice point identifies the clinical features that prompt concern for inflicted skeletal injury and outlines a management approach based on current literature and published guidelines, including the clinician's duty to report suspicion of child abuse to child welfare authorities. This document does not address isolated skull fractures.
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Affiliation(s)
| | | | - Margaret Colbourne
- Canadian Paediatric Society, Child and Youth Maltreatment Section, Ottawa, Ontario
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Abstract
The management of pediatric fractures has evolved over the past several decades, and many injuries that were previously being managed nonoperatively are now being treated surgically. The American Academy of Orthopaedic Surgeons has developed clinical guidelines to help guide decision making and streamline patient care for certain injuries, but many topics remain controversial. This article analyzes the evidence regarding management of 5 of the most common and controversial injuries in pediatric orthopedics today.
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Affiliation(s)
- Elizabeth W Hubbard
- Department of Orthopaedic Surgery, Shriner's Hospital for Children, 110 Conn Terrace, Lexington, KY 40508, USA
| | - Anthony I Riccio
- Department of Orthopaedic Surgery, Texas Scottish Rite Hospital for Children, 2222 Welborn Street, Dallas, TX 75219, USA.
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Yuma-Guerrero P, Orsi R, Lee PT, Cubbin C. A systematic review of socioeconomic status measurement in 13 years of U.S. injury research. JOURNAL OF SAFETY RESEARCH 2018; 64:55-72. [PMID: 29636170 PMCID: PMC10372816 DOI: 10.1016/j.jsr.2017.12.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/09/2017] [Accepted: 12/05/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The purpose of this review was to assess the impact of socioeconomic status (SES) on injury and to evaluate how U.S. injury researchers have measured SES over the past 13years in observational research studies. DESIGN & METHODS This systematic review included 119 US injury studies indexed in PubMed between January 1, 2002 and August 31, 2015 that used one or more individual and/or area-level measures of SES as independent variables. Study findings were compared to the results of a previous review published in 2002. RESULTS Findings indicate SES remains an important predictor of injury. SES was inversely related to injury in 78 (66%) of the studies; inverse relationships were more consistently found in studies of fatal injury (77.4%) than in studies of non-fatal injury (58%). Approximately two-thirds of the studies (n=73, 61%) measured SES along a gradient and 59% used more than one measure of SES (n=70). Studies that used a gradient measure of SES and/or more than one measure of SES identified significant relationships more often. These findings were essentially equivalent to those of a similar 2002 review (Cubbin & Smith, 2002). CONCLUSIONS There remains a need to improve measurement of SES in injury research. Public health training programs should include best practices for measurement of SES, which include: measuring SES along a gradient, selecting SES indicators based on the injury mechanism, using the smallest geographic region possible for area-level measures, using multiple indicators when possible, and using both individual and area-level measures as both contribute independently to injury risk. Area-level indicators of SES are not accurate estimates of individual-level SES. PRACTICAL APPLICATIONS Injury researchers should measure SES along a gradient and incorporate individual and area-level SES measures that are appropriate to the injury outcome under study.
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Affiliation(s)
- Paula Yuma-Guerrero
- Colorado State University, College of Health and Human Sciences, School of Social Work, 127 Education, 1586 Campus Delivery, Fort Collins, CO 80523-1586, United States.
| | - Rebecca Orsi
- Colorado State University, College of Health and Human Sciences, School of Social Work, 127 Education, 1586 Campus Delivery, Fort Collins, CO 80523-1586, United States
| | - Ping-Tzu Lee
- Colorado State University, College of Health and Human Sciences, School of Social Work, 127 Education, 1586 Campus Delivery, Fort Collins, CO 80523-1586, United States
| | - Catherine Cubbin
- The University of Texas at Austin, School of Social Work, Austin, TX, United States
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Talbot C, Davis N, Majid I, Young M, Bouamra O, Lecky FE, Jones S. Fractures of the femoral shaft in children: national epidemiology and treatment trends in England following activation of major trauma networks. Bone Joint J 2018; 100-B:109-118. [PMID: 29305459 DOI: 10.1302/0301-620x.100b1.bjj-2016-1315.r3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The aim of this study was to describe the epidemiology of closed isolated fractures of the femoral shaft in children, and to compare the treatment and length of stay (LOS) between major trauma centres (MTCs) and trauma units (TUs) in England. PATIENTS AND METHODS National data were obtained from the Trauma and Audit Research Network for all isolated, closed fractures of the femoral shaft in children from birth to 15 years of age, between 2012 and 2015. Age, gender, the season in which the fracture occurred, non-accidental injury, the mechanism of injury, hospital trauma status, LOS and type of treatment were recorded. RESULTS A total of 1852 fractures were identified. The mean annual incidence was 5.82 per 100 000 children (95% confidence interval (CI) 5.20 to 6.44). The age of peak incidence was two years for both boys and girls; this decreased with increasing age. Children aged four to six years treated in MTCs were more likely to be managed with open reduction and internal fixation compared with those treated in TUs (odds ratio 3.20; 95% CI 1.12 to 9.14; p = 0.03). The median LOS was significantly less in MTCs than in TUs for children aged between 18 months and three years treated in both a spica (p = 0.005) and traction (p = 0.0004). CONCLUSION This study highlights the current national trends in the management of closed isolated fractures of the femoral shaft in children following activation of major trauma networks in 2012. Future studies focusing on the reasons for the differences which have been identified may help to achieve more consistency in the management of these injuries across the trauma networks. Cite this article: Bone Joint J 2018;100-B:109-18.
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Affiliation(s)
- C Talbot
- Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK
| | - N Davis
- Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK
| | - I Majid
- Royal Manchester Children's Hospital
| | - M Young
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester M6 8HD, UK
| | - O Bouamra
- University of Manchester, Trauma Audit and Research Network, Salford, Manchester M6 8HD, UK
| | - F E Lecky
- University of Sheffield, School of Health and Related Research, Western Bank, Sheffield S10 2TN, UK
| | - S Jones
- Royal Manchester Children's Hospital
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Sargent MC. Single-Leg Spica Cast Application for Treatment of Pediatric Femoral Fracture. JBJS Essent Surg Tech 2017; 7:e26. [PMID: 30233961 DOI: 10.2106/jbjs.st.15.00070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Use of a single-leg spica cast for femoral fractures in ambulatory children 1 to 5 years of age facilitates care and mobilization of the patient. It may allow a shorter duration of cast treatment than is possible with a traditional one and one-half-leg spica cast, particularly in patients 1 to 3 years of age. The single-leg spica is indicated for children who are small enough to be lifted safely in the cast and who have an isolated, closed, low-energy femoral shaft fracture. The procedure consists of the following steps:Step 1: Obtain adequate sedation. General anesthesia should be used in the operating room, whereas conscious sedation may be used in the emergency or procedure room setting. The location of the procedure should be determined by available resources.Step 2: Determine the position of optimal alignment by visual examination of the thigh and leg. If intraoperative imaging is available, assess fracture stability by performing the telescope test described by Thompson et al.1-i.e., by gently applying axial load to the thigh to assess for shortening under fluoroscopic monitoring. Shortening of >3 cm reflects substantial periosteal stripping and is associated with an increased risk of loss of reduction in the cast. Alternative stabilization techniques should be considered for grossly unstable fractures with a positive telescope test. Use of intramedullary nails, external fixation, or traction with delayed cast application may decrease the risk of excessive shortening or unacceptable angulation of the fracture in the cast.Step 3: Apply a stockinette or waterproof pantaloons cast liner to the torso and involved lower extremity.Step 4: Position the patient on a spica-cast application table, which provides a support under the thorax and head with a strut that supports the spine and pelvis to the sacrum, allowing application of the cast material to the pelvic area and involved extremity. Position the patient on the table with the involved extremity flexed 30° to 60° at the hip and 30° to 60° at the knee and the contralateral leg supported. Greater flexion makes it easier to fit the child into a car seat or high chair and to carry him/her on the caretaker's hip, whereas flexing the hip and knee less allows the patient to bear weight more easily. However, Illgen et al.2 found knee flexion of <50° to be associated with an increased risk of reduction loss. More proximal fractures are better treated with greater hip flexion because of their tendency to drift into apex anterior angulation.Step 5: Overwrap the cast liner from nipple line to ankle with cotton or synthetic undercast padding to prevent pressure sores. Some families prefer waterproof cast padding as it allows the child to be immersed for bathing, but it provides less padding at pressure points and increases the cost of the cast.Step 6: Apply fiberglass or plaster cast material starting 1 in (2.5 cm) below the edge of the cast padding and ending 1 in above the malleoli to allow the edges of the cast to be adequately padded when the liner is folded back.Step 7: Apply an iliac crest mold to stabilize the hip, and apply an anterior and valgus mold to the involved thigh to recreate the anterior bow and address the tendency of femoral shaft fractures to drift into varus.Step 8: Trim and finish the cast. Inspect the groin region for rough edges and trim them as needed using the cast saw or bandage scissors. Cast edges should be "petalled with" (covered with short strips of) moleskin as needed.Step 9: After the cast is hard, remove the patient from the spica table and wake him/her up. Place a smaller diaper over the groin inside the cast to prevent cast soiling and a second, larger diaper over the outside of the cast to hold the smaller diaper in place. Following cast application, distal neurovascular status is assessed. The caretakers are trained in cast care and safe patient transport. The fit of the car seat is checked prior to discharge from the emergency room or hospital. Follow-up radiographs with the patient in the cast should be obtained 10 days after cast application. Angulation of ≤15° and shortening of <2 cm can generally be accepted in patients with a midshaft fracture. Angulation of >15° can often be managed with wedging of the cast in the clinic. Excessive shortening may require reapplication of the cast or a change to another stabilization method. Single-leg spica treatment of femoral fractures in children ≤5 years of age has provided reliable outcomes with few complications. Usually, the cast can be removed 4 to 6 weeks following application.
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Bell N, Cai B. The reliability of the American Community Survey for injury surveillance. Inj Prev 2017; 23:244-262. [PMID: 28733466 DOI: 10.1136/injuryprev-2016-042122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 09/09/2016] [Accepted: 09/18/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND To evaluate the reliability and predictability of 49 socioeconomic indicators constructed from the annual and multiyear American Community Survey (ACS) data cycles for monitoring injury inequalities across the USA. METHODS Cross-sectional analysis of the 2006-2013 annual and multiyear county-level ACS data cycles. Indicator reliability was assessed using the margin of error and coefficient of variation (CV). Overlapping multiyear data cycles were assessed for statistical dependence in the estimates. Negative binomial regression models were constructed from a selection of the most reliable indicators over time and across all data cycles using all-cause unintentional and homicide-related mortality records from the National Center for Health Statistics (NCHS). RESULTS Fewer than half of all indicators for each data cycle generated 'high reliability' CV estimates for at least 95% of all census counties. Indicator reliability did not linearly improve with increasing sample size afforded from the multiyear surveys. On average, changes in socioeconomic conditions for the same geographic areas were statistically significantly different (p<0.05) in 14% (rage 0-99%) to 16% (rage 0-93%) of all overlapping multiyear data cycles. ACS indicators that were among the most reliable across data cycles corroborated variable relationships derived using estimates from the 2000 decennial census and corresponding NCHS records for that year. CONCLUSIONS Few of the socioeconomic indicators previously used to measure injury disparities are consistently reliable across all ACS data cycles. Researchers should be judicious when selecting consecutive multiyear data cycles to approximate changes in annual socioeconomic conditions. Among the indicators that are reliable, it is advisable to use estimates from the annual ACS data cycle as a crude barometer of injury inequalities and the multiyear files to confirm and add precedence to national trends every three and five years.
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Affiliation(s)
- Nathaniel Bell
- College of Nursing, University of South Carolina, Columbia, South Carolina, USA.,Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA.,Department of Surgery, University of South Carolina, Columbia, South Carolina, USA
| | - Bo Cai
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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John R, Sharma S, Raj GN, Singh J, C. V, RHH A, Khurana A. Current Concepts in Paediatric Femoral Shaft Fractures. Open Orthop J 2017; 11:353-368. [PMID: 28603567 PMCID: PMC5447924 DOI: 10.2174/1874325001711010353] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 07/09/2016] [Accepted: 07/15/2016] [Indexed: 12/12/2022] Open
Abstract
Pediatric femoral shaft fractures account for less than 2% of all fractures in children. However, these are the most common pediatric fractures necessitating hospitalization and are associated with prolonged hospital stay, prolonged immobilization and impose a significant burden on the healthcare system as well as caregivers. In this paper, the authors present a comprehensive review of epidemiology, aetiology, classification and managemement options of pediatric femoral shaft fractures.
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Affiliation(s)
- Rakesh John
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Siddhartha Sharma
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gopinathan Nirmal Raj
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jujhar Singh
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Varsha C.
- Department of Paediatrics, Indraprastha Apollo Hospital, New Delhi, India
| | - Arjun RHH
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankit Khurana
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Four Weeks in a Single-Leg Weight-Bearing Hip Spica Cast is Sufficient Treatment for Isolated Femoral Shaft Fractures in Children Aged 1 to 3 Years. J Pediatr Orthop 2017; 36:680-4. [PMID: 26090979 DOI: 10.1097/bpo.0000000000000523] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hip spica casting regimens for the treatment of femoral shaft fractures in a pediatric population aged 1 to 3 years vary. Patient charts were reviewed to determine if there are any clinical differences between 3 and 4 weeks in an ambulatory single-leg hip spica (SLHS) cast versus 6 to 8 weeks in a standard double-leg, non-weight-bearing hip spica cast. METHODS The medical records of 109 patients with femoral shaft fractures treated with a hip spica casting from January 1, 2008 to December 31, 2011 were examined. After exclusions, 94 patients were eligible for inclusion in the study. Patient records were assessed, noting age, weight, type of cast, time in cast, and complications. All casts were applied by senior pediatric orthopaedic surgeons at a single institution. RESULTS Two groups were evaluated: 59 patients in the SLHS group and 35 in the double-leg hip spica group. The 2 groups were demographically similar with an average age of 2 years, 70.2% of patients were male, 45.7% were black, and 35.1% were white. The average time to cast removal was 4.1 weeks for the single-leg group and 5.3 weeks for the double-leg group (P<0.001). Both groups had similar low rates of loss of reduction. The double-leg group had a significantly higher incidence of clinically significant limb-length discrepancy (7/35, 20%), compared with the single-leg group (1/59, 1.7%, P=0.004). In addition, the double-leg group also had more skin problems (11/35, 31.4%) compared with the single-leg group (6/59, 10.2%, P=0.013). Seventeen patients in the single-leg group were documented as walking in the cast as compared with no patients in the double-leg group (P<0.001). CONCLUSIONS Patients treated with a single-leg spica cast for 4 weeks had fewer complications than patients treated in a traditional double-leg cast. Femoral shaft fractures in patients less than 4 years old can be treated in a weight-bearing SLHS casts for approximately 4 weeks with fewer alignment and skin complications. LEVEL OF EVIDENCE Level III-clinical retrospective comparative study.
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Rapp M, Kraus R, Illing P, Sommerfeldt DW, Kaiser MM. Behandlung der Femurschaftfraktur bei Kindern und Jugendlichen mit einem Körpergewicht ≥50 kg. Unfallchirurg 2017; 121:47-57. [DOI: 10.1007/s00113-017-0313-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Schwarzkopf R, Bauer A, Chaurasia A, Hall AM, Zurakowski D, Scott RD. Distal femoral aspect ratios throughout childhood: an MRI study of normative data and sex comparisons. J Pediatr Orthop B 2016; 25:241-4. [PMID: 26895290 DOI: 10.1097/bpb.0000000000000279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The ratio of anteroposterior (AP) to medial-lateral (ML) dimensions of the distal femur in adults differs by sex. The average AP/ML dimension ratios are 0.82 for females and 0.79 for males. How and when this difference develops is not yet understood. In this study, the distal femoral dimensions and physeal development of 345 participants younger than 21 years of age were evaluated by MRI. Regression analysis indicated a significant increase in the AP/ML ratio with increasing age for both sexes. In girls, the ratio increased from 0.63 at ages 0-5 years to 0.76 at 15-20 years. In boys, the ratio increased from 0.61 to 0.73 over the same age groups. Female distal femur dimensions are narrower than that of males from birth. Throughout childhood, both sexes show gradual increases in AP/ML ratios. After closure of the physes, the AP/ML ratio in children approaches adult values, with females continuing to have relatively narrower dimensions than males.
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Affiliation(s)
- Ran Schwarzkopf
- aDepartment of Orthopaedic Surgery, NYU Langone Medical Center Hospital For Joint Diseases, Division of Adult Reconstruction, New York, New York bDepartment of Orthopaedic Surgery, Shriners Hospital for Children Northern California, Sacramento, California cBoston Children's Hospital dNew England Baptist Hospital, Boston, Massachusetts, USA
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Isik C, Kurtulmus T, Saglam N, Saka G, Akpinar F, Sarman H. KIRSCHNER WIRE VERSUS TITANIUM ELASTIC NAILS IN PEDIATRIC FEMORAL SHAFT FRACTURES. ACTA ORTOPEDICA BRASILEIRA 2015; 23:255-8. [PMID: 26981033 PMCID: PMC4775477 DOI: 10.1590/1413-785220152305145030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of intramedullary fixation using the Kirschner-wire (K-wire) compared to the titanium elastic nail (TEN) in pediatric femoral shaft fractures. METHODS A sample of 42 pediatric patients with a mean age of 6.55±2.42 years (range 4-11 years) presenting femoral shaft fractures underwent intramedullary fixation using the K-wire or TEN. RESULTS There was no significant difference found between groups, of which 16 (38.1%) patients were treated with K-wire and 26 (61.9%) patients were treated with TEN in terms of union duration. Moreover, none of the patients showed nonunion or a delayed union. CONCLUSIONS The use of adjusted K-wire instead of TEN in the intramedullary fixation of femoral shaft fractures in selected children may be an advantageous surgical option due to the lower cost, easy accessibility and no need for a second surgery for implant removal. Level of Evidence III, Retrospective Study.
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Affiliation(s)
- Cengiz Isik
- Abant İzzet Baysal University Medical School, Turkey
| | | | | | - Gursel Saka
- Umraniye Training and Research Hospital, Turkey
| | - Fuat Akpinar
- Abant İzzet Baysal University Medical School, Turkey
| | - Hakan Sarman
- Abant İzzet Baysal University Medical School, Turkey
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Bell N, Arrington A, Adams SA. Census-based socioeconomic indicators for monitoring injury causes in the USA: a review. Inj Prev 2015; 21:278-84. [PMID: 25678685 PMCID: PMC4518757 DOI: 10.1136/injuryprev-2014-041444] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 11/21/2014] [Accepted: 12/06/2014] [Indexed: 01/07/2023]
Abstract
BACKGROUND Unlike the UK or New Zealand, there is no standard set of census variables in the USA for characterising socioeconomic (SES, socioeconomic status) inequalities in health outcomes, including injury. We systematically reviewed existing US studies to identify conceptual and methodological strengths and limitations of current approaches to determine those most suitable for research and surveillance. METHODS We searched seven electronic databases to identify census variables proposed in the peer-reviewed literature to monitor injury risk. Inclusion criteria were that numerator data were derived from hospital, trauma or vital statistics registries and that exposure variables included census SES constructs. RESULTS From 33 eligible studies, we identified 70 different census constructs for monitoring injury risk. Of these, fewer than half were replicated by other studies or against other causes, making the majority of studies non-comparable. When evaluated for a statistically significant relationship with a cause of injury, 74% of all constructs were predictive of injury risk when assessed in pairwise comparisons, whereas 98% of all constructs were significant when aggregated into composite indices. Fewer than 30% of studies selected SES constructs based on known associations with injury risk. CONCLUSIONS There is heterogeneity in the conceptual and methodological approaches for using census data for monitoring injury risk as well as in the recommendations as to how these constructs can be used for injury prevention. We recommend four priority areas for research to facilitate a more unified approach towards use of the census for monitoring socioeconomic inequalities in injury risk.
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Affiliation(s)
- Nathaniel Bell
- College of Nursing, University of South Carolina, Columbia, South Carolina, USA
| | - Amanda Arrington
- Department of Surgery, Marshall University, Huntington, West Virginia, USA
| | - Swann Arp Adams
- College of Nursing, University of South Carolina, Columbia, South Carolina, USA
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An observational cohort study of the adoption of elastic stable intramedullary nailing for the treatment of pediatric femur fractures in Kumasi, Ghana. World J Surg 2015; 38:2818-24. [PMID: 24964754 DOI: 10.1007/s00268-014-2664-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND In high- and middle-income countries, elastic stable intramedullary nailing (ESIN) is the commonest treatment of femur fractures in children 5-11 years of age. At Komfo Anokye Teaching hospital (KATH) in Kumasi, Ghana, prior to this study all pediatric femur fractures were treated with skin traction to union. This study was designed to report the early results and costs of the adoption of ESIN at KATH to provide data to other low- and middle-income sites considering adoption of this surgical technique. METHODS An observational cohort study that included 84 pediatric patients ages 3-14 years presenting with closed femur fractures and treated with either skin traction or ESIN. Multivariate logistic regression was used to compare the rate of treatment success between treatment groups. RESULTS Treatment success (coronal and sagittal angulation less than 10 ° and shortening less than 15 mm at osseous union) was achieved in 92 % of the ESIN group versus 67 % of the skin traction group (odds ratio for ESIN group 9.28 (1.6-54.7); p = 0.0138). Average length of stay was significantly lower in the ESIN group (p = 0.001), but charges to patients were higher in the ESIN group (p < 0.001) because of the high cost of implants. CONCLUSIONS The initial experience of operative treatment of femoral shaft fractures in children using ESIN was positive, with improved rates of treatment success and no surgical complications. Because of the high cost of implants, direct costs of treatment remained higher with ESIN despite reductions in length of hospital stay.
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Windolf M, Fischer MF, Popp AW, Matthys R, Schwieger K, Gueorguiev B, Hunter JB, Slongo TF. End caps prevent nail migration in elastic stable intramedullary nailing in paediatric femoral fractures: a biomechanical study using synthetic and cadaveric bones. Bone Joint J 2015; 97-B:558-63. [PMID: 25820898 DOI: 10.1302/0301-620x.97b4.34169] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
End caps are intended to prevent nail migration (push-out) in elastic stable intramedullary nailing. The aim of this study was to investigate the force at failure with and without end caps, and whether different insertion angles of nails and end caps would alter that force at failure. Simulated oblique fractures of the diaphysis were created in 15 artificial paediatric femurs. Titanium Elastic Nails with end caps were inserted at angles of 45°, 55° and 65° in five specimens for each angle to create three study groups. Biomechanical testing was performed with axial compression until failure. An identical fracture was created in four small adult cadaveric femurs harvested from two donors (both female, aged 81 and 85 years, height 149 cm and 156 cm, respectively). All femurs were tested without and subsequently with end caps inserted at 45°. In the artificial femurs, maximum force was not significantly different between the three groups (p = 0.613). Push-out force was significantly higher in the cadaveric specimens with the use of end caps by an up to sixfold load increase (830 N, standard deviation (SD) 280 vs 150 N, SD 120, respectively; p = 0.007). These results indicate that the nail and end cap insertion angle can be varied within 20° without altering construct stability and that the risk of elastic stable intramedullary nailing push-out can be effectively reduced by the use of end caps.
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Affiliation(s)
- M Windolf
- AO Research Institute Davos, Davos, Switzerland
| | - M F Fischer
- AO Research Institute Davos, Davos, Switzerland
| | - A W Popp
- University of Berne, Berne, Switzerland
| | | | - K Schwieger
- AOTK System, AO Foundation, Davos, Switzerland
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Baker R, Orton E, Tata LJ, Kendrick D. Risk factors for long-bone fractures in children up to 5 years of age: a nested case-control study. Arch Dis Child 2015; 100:432-7. [PMID: 25398446 PMCID: PMC4413839 DOI: 10.1136/archdischild-2013-305715] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 10/24/2014] [Indexed: 11/03/2022]
Abstract
AIM To investigate risk factors for first long-bone fractures in children up to 5 years old in order to provide evidence about which families could benefit from injury prevention interventions. METHODS Population-based matched nested case-control study using The Health Improvement Network, a UK primary care research database, 1988-2004. Maternal, household and child risk factors for injury were assessed among 2456 children with long-bone fractures (cases). 23,661 controls were matched to cases on general practice. Adjusted ORs and 95% CIs were estimated using conditional logistic regression. RESULTS Fractures of long-bones were independently associated with younger maternal age and higher birth order, with children who were the fourth-born in the family, or later, having a threefold greater odds of fracture compared to first-born children (adjusted OR 3.12, 95% CI 2.08 to 4.68). Children over the age of 1 year had a fourfold (13-24 months, adjusted OR 4.09 95% CI 3.51 to 4.76) to fivefold (37+ months, adjusted OR 4.88 95% CI 4.21 to 5.66) increase in the odds of a long-bone fracture compared to children aged 0-12 months. Children in families with a history of maternal alcohol misuse had a raised odds of long-bone fracture (adjusted OR 2.33, 95% CI 1.13 to 4.82) compared to those with no documented history. CONCLUSIONS Risk factors for long-bone fractures in children less than 5 years old included age above 1 year, increasing birth order, younger maternal age and maternal alcohol misuse. These risk factors should be used to prioritise families and communities for injury prevention interventions.
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Affiliation(s)
- Ruth Baker
- Division of Epidemiology and Public Health, Nottingham City Hospital, University of Nottingham, Nottingham, UK
| | - Elizabeth Orton
- Division of Primary Care, University Park, University of Nottingham, Nottingham, UK
| | - Laila J Tata
- Division of Epidemiology and Public Health, Nottingham City Hospital, University of Nottingham, Nottingham, UK
| | - Denise Kendrick
- Division of Primary Care, University Park, University of Nottingham, Nottingham, UK
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The management of pediatric subtrochanteric femur fractures with a statically locked intramedullary nail. J Orthop Trauma 2015; 29:e7-e11. [PMID: 24854667 DOI: 10.1097/bot.0000000000000156] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate locked intramedullary (IM) fixation as an alternative treatment method for children with subtrochanteric fractures. DESIGN Retrospective review. SETTING Level 1 trauma center in a Children's Hospital. PATIENTS/PARTICIPANTS Pediatric patients with subtrochanteric femur fractures with open growth plates. INTERVENTION All patients were treated with a lateral entry IM locking nail. OUTCOME MEASUREMENTS Patients were followed until full fracture consolidation or until implant removal. Data on time to full weight bearing, return to full activity, residual pain, any form of gait abnormality, and any other complication from follow-up visits were collected. RESULTS There were 9 males and 1 female patient with an average age of 12 years and average follow-up of 22 months. Most of the fractures occurred secondary to high-energy trauma. Partial weight bearing was started at 24 days and full at 66 days. Implants were removed on average at 11 months after implantation. There were neither intraoperative complications nor major complications in the postoperative period recorded after removal. Two patients presented with a longer limb on the affected side, both 8 mm, and 2 presented with asymptomatic grade I heterotopic ossification. CONCLUSIONS The use of a statically locked lateral entry IM nail for subtrochanteric femur fractures in children is a safe and efficacious method of treatment with few complications and risks and satisfactory outcomes in children over the age of 8 years. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Wood JN, Fakeye O, Mondestin V, Rubin DM, Localio R, Feudtner C. Prevalence of abuse among young children with femur fractures: a systematic review. BMC Pediatr 2014; 14:169. [PMID: 24989500 PMCID: PMC4085378 DOI: 10.1186/1471-2431-14-169] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 06/19/2014] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Clinical factors that affect the likelihood of abuse in children with femur fractures have not been well elucidated. Consequently, specifying which children with femur fractures warrant an abuse evaluation is difficult. Therefore the purpose of this study is to estimate the proportion of femur fractures in young children attributable to abuse and to identify demographic, injury and presentation characteristics that affect the probability that femur fractures are secondary to abuse. METHODS We conducted a systematic review of published articles written in English between January 1990 and July 2013 on femur fracture etiology in children less than or equal to 5 years old based on searches in PubMed/MEDLINE and CINAHL databases. Data extraction was based on pre-defined data elements and included study quality indicators. A meta-analysis was not performed due to study population heterogeneity. RESULTS Across the 24 studies reviewed, there were a total of 10,717 children less than or equal to 60 months old with femur fractures. Among children less than 12 months old with all types of femur fractures, investigators found abuse rates ranging from 16.7% to 35.2%. Among children 12 months old or greater with femur fractures, abuse rates were lower: from 1.5% - 6.0%. In multiple studies, age less than 12 months, non-ambulatory status, a suspicious history, and the presence of additional injuries were associated with findings of abuse. Diaphyseal fractures were associated with a lower abuse incidence in multiple studies. Fracture side and spiral fracture type, however, were not associated with abuse. CONCLUSIONS Studies commonly find a high proportion of abuse among children less than 12 months old with femur fractures. The reported trauma history, physical examination findings and radiologic results must be examined for characteristics that increase or decrease the likelihood of abuse determination.
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Affiliation(s)
- Joanne N Wood
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, 3535 Market Street, Floor 15, Philadelphia PA19104, Pennsylvania
- Leonard Davis Institute of Health Economics, Colonial Penn Center, 3641 Locust Walk, Philadelphia 19104, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia 19104, Pennsylvania
| | - Oludolapo Fakeye
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, 3535 Market Street, Floor 15, Philadelphia PA19104, Pennsylvania
| | - Valerie Mondestin
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, 3535 Market Street, Floor 15, Philadelphia PA19104, Pennsylvania
| | - David M Rubin
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, 3535 Market Street, Floor 15, Philadelphia PA19104, Pennsylvania
- Leonard Davis Institute of Health Economics, Colonial Penn Center, 3641 Locust Walk, Philadelphia 19104, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia 19104, Pennsylvania
| | - Russell Localio
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia 19104, Pennsylvania
| | - Chris Feudtner
- Division of General Pediatrics and PolicyLab, The Children’s Hospital of Philadelphia, 3535 Market Street, Floor 15, Philadelphia PA19104, Pennsylvania
- Leonard Davis Institute of Health Economics, Colonial Penn Center, 3641 Locust Walk, Philadelphia 19104, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia 19104, Pennsylvania
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Black KJL, Bevan CA, Murphy NG, Howard JJ, Cochrane Bone, Joint and Muscle Trauma Group. Nerve blocks for initial pain management of femoral fractures in children. Cochrane Database Syst Rev 2013; 2013:CD009587. [PMID: 24343768 PMCID: PMC11751595 DOI: 10.1002/14651858.cd009587.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children and adolescents with femoral fractures are almost always admitted to hospital. They invariably start their hospital experience in the Emergency Department, often requiring transfer to a specialist children's hospital. They require analgesia or anaesthesia so that radiographs can be obtained and for management of their fractures. The initial care process involves from two to six transfers from stretcher to stretcher/imaging/operating-suite table or hospital bed within the first few hours, so prompt pain relief is essential. Systemic analgesia can be provided orally or parenterally. Alternatively, a nerve block may be used where local anaesthetic is injected around a nerve to block sensation or freeze the involved area. OBJECTIVES To assess the effects (benefits and harms) of femoral nerve block (FNB) or fascia iliaca compartment block (FICB) for initial pain management of children with fractures of the femur (thigh bone) in the pre-hospital or in-hospital emergency setting, with or without systemic analgesia. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (11 January 2013), the Cochrane Central Register of Controlled Trials (2012 Issue 12), MEDLINE (1946 to January Week 1 2013), EMBASE (1980 to 2013 Week 01), Google Scholar (31 January 2013) and trial registries (31 January 2013). We handsearched recent issues of specialist journals and references of relevant articles. SELECTION CRITERIA Randomised and quasi-randomised controlled trials assessing the effects of FNB or FICB for initial pain management compared with systemic opiates in children (aged under 18 years) with fractures of the femur receiving pre-hospital or in hospital emergency care. Primary outcomes included failure of analgesia at 30 minutes, pain levels during procedures and transfers (e.g. to a stretcher or hospital ward) for up to eight hours, and adverse effects. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data using a pre-piloted form. Two authors independently assessed the risk of bias for the included study and assessed quality of the evidence for each outcome using the GRADE approach; i.e. as very low, low, moderate or high. Meta-analysis of results was not possible as we found only one trial that could be included in the review. MAIN RESULTS We included one randomised trial of 55 children aged between 16 months to 15 years. It compared anatomically-guided FICB versus systemic analgesia with intravenous morphine sulphate. The small sample size and the high risk of bias relating to lack of blinding resulted in a low quality rating for all outcomes.Overall, the trial provided low quality evidence for better pain management in the FICB group. Fewer children in the FICB group had analgesia failure at 30 minutes than in the morphine group (2/26 (8%) versus 8/28 (29%); risk ratio (RR) 0.33, 95% confidence interval (CI) 0.09 to 1.20; P value 0.09). The trial did not report on pain during procedures or transfers, or application of analgesia. The trial provided low quality evidence that FICB has a better safety profile than morphine, with only four (15%) reports of redness and pain at the injection site, and no reports of the type of adverse effects of systematic analgesia that occurred in the morphine group, such as respiratory depression (six cases (21%)) and vomiting (four cases (14%)). No long-term adverse events were reported for either intervention. Clinically significant pain relief was achieved in both groups at five minutes; with limited evidence of greater initial pain relief in the FICB group. Based on an inspection of graphically-presented data, at least 46% (12/26) of children in the FICB group had no supplementary medication (mainly analgesia) for the six hours of the study, while only 5% (1 or 2/28) of children in the intravenous morphine group went without additional analgesia. There was insufficient evidence to determine whether child or parental satisfaction with the method of analgesia favoured either method. Resource use was not measured. AUTHORS' CONCLUSIONS Low quality evidence from one small trial suggests that FICB provides better and longer lasting pain relief with fewer adverse events than intravenous opioids for femur fractures in children. Well conducted and reported randomised trials that compare nerve blocks (both FNB and FICB) with systemic analgesia and that use validated pain scores are needed.
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Affiliation(s)
- Karen JL Black
- University of British ColumbiaDivision of Emergency Medicine, Department of PediatricsBC Children's Hospital4480 Oak StVancouverBCCanadaV6H 3N1
| | - Catherine A Bevan
- Royal Alexandra Children's HospitalChildrens' Emergency DepartmentEastern RoadBrightonSussexUKBN2 5BE
| | - Nancy G Murphy
- IWK Regional Poison CentreIWK Emergency Department5950 University AvenueHalifaxNSCanadaB3K 6R8
| | - Jason J Howard
- IWK Health CentreDepartment of SurgeryPO Box 9700, 5850 University AvenueHalifaxNSCanadaB3K 6R8
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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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Rigid intramedullary nail fixation of femoral fractures in adolescents: what evidence is available? J Orthop Traumatol 2013; 15:147-53. [PMID: 24077687 PMCID: PMC4182647 DOI: 10.1007/s10195-013-0270-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 09/01/2013] [Indexed: 12/23/2022] Open
Abstract
Background Femoral fracture in adolescents is a significant injury. It is generally agreed that operative fixation is the treatment of choice, and rigid intramedullary nail fixation is a treatment option. However, numerous types of rigid nails to fix adolescent femoral fractures have been described. Hence, the aim of this paper was to collate and evaluate the available evidence for managing diaphyseal femoral fractures in adolescents using rigid intramedullary nails. Materials and methods A literature search was undertaken using the healthcare database website (http://www.library.nhs.uk/hdas). Medline, CINAHL, Embase, and the Cochrane Library databases were searched to identify prospective and retrospective studies of rigid intramedullary nail fixation in the adolescent population. Results The literature search returned 1,849 articles, among which 51 relevant articles were identified. Of these 51 articles, 23 duplicates were excluded, so a total of 28 articles were reviewed. First-generation nails had a high incidence of limb length discrepancy (Küntscher 5.8 %, Grosse–Kempf 9 %), whilst second-generation nails had a lower incidence (Russell–Taylor 1.7 %, AO 2.6 %). Avascular necrosis was noted with solid Ti nails (2.6 %), AO femoral nails (1.3 %) and Russell–Taylor nails (0.85 %). These complications have not been reported with the current generation of nails. Conclusions Rigid intramedullary nail fixation of femoral fractures in adolescents is a useful procedure with good clinical results. A multiplanar design and lateral trochanteric entry are key to a successful outcome of titanium alloy nail fixation.
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Rush JK, Kelly DM, Sawyer JR, Beaty JH, Warner WC. Treatment of pediatric femur fractures with the Pavlik harness: multiyear clinical and radiographic outcomes. J Pediatr Orthop 2013; 33:614-7. [PMID: 23774204 DOI: 10.1097/bpo.0b013e318292464a] [Citation(s) in RCA: 13] [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 Femur fractures account for 1.4% to 1.7% of all pediatric fractures. The use of the Pavlik harness has been described for infants; however, previous reports have included only short-term follow-up. This study describes the multiyear clinical and radiographic results from patients younger than 6 months of age treated with a Pavlik harness. METHODS The clinical and radiographic records were reviewed for all children under the age of 6 months who were treated with a Pavlik harness for an isolated femoral shaft fracture at a level 1 pediatric trauma center. Radiographs were obtained at final follow-up, as well as a standing full-length anteroposterior scanogram. Clinical examination was completed and inquiry regarding patient activity limitations, complications of treatment, and overall parent/provider satisfaction was made. RESULTS Ten patients with 10 fractures met inclusion criteria. The average age of the patients at the time of injury was 2.2 months. The average duration of Pavlik harness treatment was 43 days (range, 31 to 54 d). The average age at final follow-up was 5.2 years (range, 2.6 to 7.3 y). At final follow-up, average angulation was 3 degrees valgus (range, 0 to 8 degrees) and 5 degrees procurvatum (range, 0 to 24 degrees). Only 1 patient had a measurable leg-length discrepancy of 7 mm at final follow-up. There were no complications noted. CONCLUSIONS It is felt that pediatric patients have a significant potential for bone remodeling and that any angulation at the time of fracture union will remodel. Our study supports this notion as the final angulation at follow-up averaged 3 degrees valgus and 5 degrees procurvatum. In the patient group presenting with >20 degrees of angulation at the time of injury, final angulation averaged 5 degrees valgus and 11 degrees procurvatum. Treatment with the Pavlik harness provides for excellent clinical outcomes with a minimal complication rate. However, some patients, especially those presenting with a high degree of angulation, may have some degree of persistent radiographic angulation.
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Affiliation(s)
- Jeremy K Rush
- Department of Orthopedic Surgery, Campbell Clinic, University of Tennessee College of Medicine, Germantown, TN 38132, USA
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von Heideken J, Svensson T, Iversen M, Blomqvist P, Haglund-Åkerlind Y, Janarv PM. Sociodemographic factors influence the risk for femur shaft fractures in children: a Swedish case-control study, 1997-2005. Acta Paediatr 2013; 102:431-7. [PMID: 23301769 DOI: 10.1111/apa.12150] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 12/28/2012] [Accepted: 12/28/2012] [Indexed: 11/29/2022]
Abstract
AIM To investigate how sociodemographic factors relate to the risk of femur shaft fractures in children and how the relationship differs by gender and age. METHODS Population-based case-control study. Swedish children (n = 1,874), 0-14 years of age, with a femur shaft fracture diagnostic code occurring between 1997 and 2005 were selected from the Swedish national inpatient register and compared with matched controls (n = 18,740). Demographic, socio-economic and injury data were based on record linkage between six Swedish registers. RESULTS The risk of femur shaft fracture increased for children with younger parents or those living in low-income households. Having a parent with a university education reduced the risk. Stratifying for gender and age group, the association between parents' age was evident only for older boys (7-14 years of age) (OR = 1.40; 95% CI 1.04-1.45), and the association between living in low-income households and fracture rate was only seen in older girls (7-14 years) (OR = 1.50; 95% CI 1.01-2.22). Family composition, number of siblings, birth order or receiving social welfare did not influence the fracture risk. CONCLUSION Sociodemographic variables influence the rate of femur shaft fractures, in older children the influence differs between boys and girls.
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Affiliation(s)
- Johan von Heideken
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
| | - Tobias Svensson
- Department of Medicine; Clinical Epidemiology Unit; Karolinska Institutet; Stockholm Sweden
| | - Maura Iversen
- Department of Physical Therapy; Northeastern University; Boston Massachusetts USA
- Division of Rheumatology, Immunology, and Allergy; Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts USA
| | - Paul Blomqvist
- Department of Medicine; Clinical Epidemiology Unit; Karolinska Institutet; Stockholm Sweden
| | | | - Per-Mats Janarv
- Department of Women's and Children's Health; Karolinska Institutet; Stockholm Sweden
- Capio Artro Clinic; Stockholm Sweden
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Capra L, Levin AV, Howard A, Shouldice M. Characteristics of femur fractures in ambulatory young children. Emerg Med J 2012; 30:749-53. [PMID: 23038693 DOI: 10.1136/emermed-2012-201547] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To determine and identify the characteristics and circumstances of femur fractures in ambulatory young children. DESIGN AND SETTING Retrospective review of 203 ambulatory children, between 1 and 5 years old, presenting with femur fractures to an urban paediatric hospital over a 10-year period. χ(2) And Student's t test were employed for statistical analysis. RESULTS The mean age was 36.6 months, with 155 (76.2%) being male. The most frequent mechanism of injury was fall from a height (n=62, 30.5%). The highest number of injuries occurred in 2-3-year-olds. The most common history in 1-2-year-olds was stumbling on/over something causing a fall. For 4-5 year olds it was road traffic accidents. Other additional physical findings were infrequent (14.3%) and not suspicious of inflicted injury. Child protective services concluded three of the cases to be likely non-accidental, and four cases were inconclusive but requiring close follow-up. Of these seven children, six occurred in 1-2-year-olds. No distinguishing feature was noted in fracture type or location. CONCLUSIONS Femur fractures can occur with low velocity injury whether from a short fall or twisting/stumbling injury in young healthy ambulatory children.
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Affiliation(s)
- Louise Capra
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Ontario, Canada
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Pierce MC, Kaczor K, Lohr D, Richter K, Starling SP. A Practical Guide to Differentiating Abusive From Accidental Fractures: An Injury Plausibility Approach. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2012. [DOI: 10.1016/j.cpem.2012.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Orton E, Kendrick D, West J, Tata LJ. Independent risk factors for injury in pre-school children: three population-based nested case-control studies using routine primary care data. PLoS One 2012; 7:e35193. [PMID: 22496906 PMCID: PMC3320631 DOI: 10.1371/journal.pone.0035193] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 03/13/2012] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Injuries in childhood are largely preventable yet an estimated 2,400 children die every day because of injury and violence. Despite this, the factors that contribute to injury occurrence have not been quantified at the population scale using primary care data. We used The Health Improvement Network (THIN) database to identify risk factors for thermal injury, fractures and poisoning in pre-school children in order to inform the optimal delivery of preventative strategies. METHODS We used a matched, nested case-control study design. Cases were children under 5 with a first medically recorded injury, comprising 3,649 thermal injury cases, 4,050 fracture cases and 2,193 poisoning cases, matched on general practice to 94,620 control children. RESULTS Younger maternal age and higher birth order increased the odds of all injuries. Children's age of highest injury risk varied by injury type; compared with children under 1 year, thermal injuries were highest in those age 1-2 (OR = 2.43, 95%CI 2.23-2.65), poisonings in those age 2-3 (OR = 7.32, 95%CI 6.26-8.58) and fractures in those age 3-5 (OR = N 3.80, 95%CI 3.42-4.23). Increasing deprivation was an important modifiable risk factor for poisonings and thermal injuries (tests for trend p ≤ 0.001) as were hazardous/harmful alcohol consumption by a household adult (OR = 1.73, 95%CI 1.26-2.38 and OR = 1.39, 95%CI 1.07-1.81 respectively) and maternal diagnosis of depression (OR = 1.45, 95%CI 1.24-1.70 and OR = 1.16, 95%CI 1.02-1.32 respectively). Fracture was not associated with these factors, however, not living in single-adult household reduced the odds of fracture (OR = 0.88, 95%CI 0.82-0.95). CONCLUSIONS Maternal depression, hazardous/harmful adult alcohol consumption and socioeconomic deprivation represent important modifiable risk factors for thermal injury and poisoning but not fractures in preschool children. Since these risk factors can be ascertained from routine primary care records, pre-school children's frequent visits to primary care present an opportunity to reduce injury risk by implementing effective preventative interventions from existing national guidelines.
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Affiliation(s)
- Elizabeth Orton
- Division of Primary Care, University Park, University of Nottingham, Nottingham, United Kingdom.
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Abstract
PURPOSE Rigid interlocking nailing for femoral shaft fracture is ideal for use in adolescents in terms of stability of the fracture and convenience for the patient. However, numerous authors have reported that rigid interlocking nailing has some limitations in this age group due to the risk of complications. We evaluated the results of intramedullary nailing for femoral shaft fractures with an interlocking humeral nail in older children and adolescents. MATERIALS AND METHODS We retrospectively reviewed records of patients treated with an interlocking humeral nail. Radiographs were examined for proximal femoral change and evidence of osteonecrosis. Outcomes were assessed by major or minor complications that occurred after operative treatment. RESULTS Twenty-four femoral shaft fractures in 23 patients were enrolled. The mean age at the time of operation was 12 years and 8 months and the mean follow- up period was 21 months. Bony union was achieved in all patients without any complications related to the procedure such as infection, nonunion, malalignment and limb length discrepancy. All fractures were clinically and radiographically united within an average eight weeks. No patients developed avascular necrosis of the femoral head and coxa valga. CONCLUSION Intramedullary nailing through the greater trochanter using a rigid interlocking humeral nail is effective and safe for the treatment of femoral shaft fractures in older children and adolescents.
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Affiliation(s)
- Hoon Park
- Department of Orthopaedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Woo Kim
- Department of Orthopaedic Surgery, Severance Children's Hospital, Yonsei University College of Medicine, Seoul, Korea
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