Abstract. Objectives. There is debate regarding the optimal surgical technique for fixing femoral diaphyseal fractures in children aged 4 to 12 years. The aim of this study was to conduct a systematic review and meta-analysis to compare the complication rate following flexible intramedullary nailing (FIN), plate fixation and external fixation (EF) for traumatic femoral diaphyseal fractures in children aged 4 to 12. Methods. We searched MEDLINE, EMBASE and CENTRAL databases for interventional and observational studies. Two independent reviewers screened, assessed quality and extracted data from the identified studies. The primary outcome was the risk of any complication. Results. Nine randomised controlled trials (RCTs) and 19 observational studies fulfilled the eligibility criteria. Within the RCTs, five analysed FIN (n=161), two analysed plates (n=51) and five analysed EF (n=168). Within the observational studies, 13 analysed FIN (n=610), seven analysed plates (n=214) and six analysed EF (n=153). The overall risk of complications was lower following plate fixation when compared to FIN (RR 0.45, 95% CI 0.28 to 0.73, p=0.001) in the observational studies. The overall risk of complications was higher following EF when compared to FIN in both RCTs (RR 1.94, 95% CI 1.25 to 3.01, p=0.003) and observational studies (RR 1.97, 95% CI 1.50 to 2.58, p<0.001). The overall risk of complications was higher following EF when compared to plate fixation in both RCTs (RR 7.42, 95% CI 1.84 to 29.98, p=0.005) and observational studies (RR 4.39, 95% CI 2.64 to 7.30, p<0.001). Conclusions. This study reports a significantly decreased relative risk of complications when femoral diaphyseal fractures in children aged 4 to 12 are managed with plates. The overall quality of evidence is low, highlighting the need for a prospective multicentre randomised trial at low risk of bias due to randomisation and outcome measurement to identify if any fixation technique is superior

Introduction and Objective. The most common paediatric orthopaedic injury requiring hospital admission is a femoral fracture. There is debate regarding the optimal surgical technique for fixing femoral diaphyseal fractures in children aged 4 to 12 years. The National Institute for Health and Care Excellence (NICE) and the American Academy of Orthopaedic Surgeons (AAOS) have issued relevant guidelines, however, there is limited evidence to support these. The aim of this study was to conduct a systematic review and meta-analysis to compare the complication rate following flexible intramedullary nailing (FIN), plate fixation and external fixation (EF) for traumatic femoral diaphyseal fractures in children aged 4 to 12. Materials and Methods. We searched MEDLINE, EMBASE and CENTRAL databases for interventional and observational studies. Two independent reviewers screened, assessed quality and extracted data from the identified studies. The primary outcome was the risk of any complication. Secondary outcomes assessed the risk of pre-specified individual complications. Results. Nine randomised controlled trials (RCTs) and 19 observational studies (six prospective and 13 retrospective) fulfilled the eligibility criteria. Within the RCTs, five analysed FIN (n=161), two analysed plates (n=51) and five analysed EF (n=168). Within the observational studies, 13 analysed FIN (n=610), seven analysed plates (n=214) and six analysed EF (n=153). The overall risk of complications was lower following plate fixation when compared to FIN fixation (RR 0.45, 95% CI 0.28 to 0.73, p=0.001) in the observational studies. The overall risk of complications was higher following EF when compared to FIN fixation in both RCTs (RR 1.94, 95% CI 1.25 to 3.01, p=0.003) and observational studies (RR 1.97, 95% CI 1.50 to 2.58, p<0.001). The overall risk of complications was higher following EF when compared to plate fixation in both RCTs (RR 7.42, 95% CI 1.84 to 29.98, p=0.005) and observational studies (RR 4.39, 95% CI 2.64 to 7.30, p<0.001). Conclusions. Although NICE and the AAOS recommend FIN for femoral diaphyseal fractures in children aged 4 to 12, this study reports a significantly decreased relative risk of complications when these injuries are managed with plates. Our findings provide valuable information to healthcare professionals who are involved in discussing the risk and benefits of different management options with patients and their families. The overall quality of evidence is low, highlighting the need for a rigorous prospective multicentre randomised trial at low risk of bias due to randomisation and outcome measurement to identify if any fixation technique is superior

Aims. Current American Academy of Orthopaedic Surgeons (AAOS) guidelines for treating femoral fractures in children aged two to six years recommend early spica casting although some individuals have recommended intramedullary stabilization in this age group. The purpose of this study was to compare the treatment and family burden of care of spica casting and flexible intramedullary nailing in this age group. Methods. Patients aged two to six years old with acute, non-pathological femur fractures were prospectively enrolled at one of three tertiary children’s hospitals. Either early closed reduction with spica cast application or flexible intramedullary nailing was accomplished under general anaesthesia. The treatment method was selected after discussion of the options by the surgeon with the family. Data were prospectively collected on patient demographics, fracture characteristics, complications, pain medication, and union. The Impact on Family Scale was obtained at the six-week follow-up visit. In all, 75 patients were included in the study: 39 in the spica group and 36 in the nailing group. The mean age of the spica group was 2.71 (2.0 to 6.9) years and the mean age of the nailing group was 3.16 (2.0 to 6.9) years. Results. All fractures healed without evidence of malunion or more than 2.0 cm of shortening. The mean Impact on Family score was 70.2 for the spica group and 63.2 (55 to 99) for the nailing group, a statistically significant difference (p = 0.024) in a univariate analysis suggesting less impairment of the family in the intramedullary nailing group. There was no significant difference between pain medication requirements in the first 24 hours postoperatively. Two patients in the spica group and one patient in the intramedullary nailing group required additional treatment under anaesthesia. Conclusion. Both early spica casting and intramedullary nailing were effective methods for treating femoral fractures in children two to six years of age. Intramedullary stabilization provides an option in this age group that may be advantageous in some social situations that depend on the child’s mobility. Fracture treatment should be individualized based on factors that extend beyond anatomical and biological factors. Cite this article: Bone Joint J 2020;102-B(8):1056–1061

Aims

Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union.

The December 2015 Children’s orthopaedics Roundup³⁶⁰ looks at: Paediatric femoral fractures: a single incision nailing?; Lateral condylar fractures: open or percutaneous?;

Forearm refracture: the risks; Tibial spine fractures; The child’s knee in MRI; The mechanics of SUFE; Idiopathic clubfoot

The August 2013 Children’s orthopaedics Roundup³⁶⁰ looks at: a multilevel approach to equinus gait; whether screening leads to needless intervention; salvage of subcapital slipped epiphysis; growing prostheses for children’s oncology; flexible nailing revisited; ultrasound and the pink pulseless hand; and slipping forearm fractures.

We analysed retrospectively the risk factors leading to femoral overgrowth after flexible intramedullary nailing in 43 children (mean age 7.1 years (3.6 to 12.0)) with fractures of the shaft of the femur. We reviewed their demographic data, mechanism of injury, associated injuries, the type and location of the fractures, the nail–canal diameter (NCD) ratios and femoral overgrowth at a mean follow-up of 40.7 months (25.2 to 92.7). At that time, the children were divided into two groups, those with femoral overgrowth of < 1 cm (Group 1), and those with overgrowth of ≥ 1 cm (Group 2). The mean femoral overgrowth of all patients was 0.6 cm at final follow-up. Overgrowth of ≥ 1 cm was noted in 11 children (25.6%). The NCD ratio was significantly lower in Group 2 than in Group 1, with an odds ratio of 30.0 (p = 0.003). We believe that a low NCD ratio is an indicator of an unstable configuration with flexible intramedullary nailing, and have identified an association between a low NCD ratio and femoral overgrowth resulting in leg-length discrepancy after flexible intramedullary nailing in paediatric femoral shaft fractures. Cite this article: Bone Joint J 2013;95-B:254–8

Background. Both-bone diaphyseal forearm fractures constitute up to 5.4% of all fractures in children under 16 years of age in the United Kingdom. Most can be managed with closed reduction and cast immobilisation. Surgical fixation options include flexible intramedullary nailing and plating. However, the optimal method is controversial. Objectives. The main purpose of this study was to systematically search for and critically appraise articles comparing functional outcomes, radiographic outcomes and complications of nailing and plating for both-bone diaphyseal forearm fractures in children. Methods. A literature search of MEDLINE (PubMed), EMBASE and Cochrane library databases using specific search terms and limits was undertaken. The critical appraisal checklist (adapted from Critical Appraisal Skills Programme-CASP, Oxford; Guyatt et al) for an article on treatment was used to aid assessment. Results. All 7 studies identified were retrospective, comparative and non-randomized. They all included patients with similar baseline characteristics. There were no statistically significant differences in group outcomes for range of forearm movement, time to fracture union and complication rates. Less operative time and better cosmesis was noted in the IM nailing groups. Some studies showed post-operative radial bow was significantly abnormal in the IM nailing groups, but did not affect forearm movement. Conclusion. Based on similar functional and radiographic outcomes, nailing seems to be a safe and effective option when compared to plating for forearm fractures in children. However, critical appraisal of the studies in this review identified some methodological deficiencies and further prospective, randomized trials are recommended

Introduction. Since 2001 we use the flexible intramedullary nailing (FIN) in bone lengthening in children. This study estimates results of EF+FIN association considering the duration of external fixation and complications. Materials and Methods. Since 2001 we performed 294 bone lengthenings (338 segments of UL and LL) in 250 children 3 to 16 years old (11.01±0.23 in average). The length discrepancy was congenital in 163 cases, the sequelae of trauma or osteomyelitis were observed in 87 patients. In group I (195 cases) the Ilizarov fixator alone was applied, in group II the Ilizarov fixator (91 cases) or TSF® (8cases) were combined with FIN. The healing index was compared between the groups of the same etiology with similar type of distraction osteosynthesis. The date of consolidation corresponded to the day of removal of the external fixator, while intramedullary nails remained in place thus protecting the bone. Healing index was calculated by relating the duration of wearing of the external fixator (in days) and the amount of lengthening (in cm). Results. Reduction of the healing index is noted in each compared category. Thus, in congenital shortening in monofocal distraction osteosynthesis of the femur the healing index decreased from 29.8 (group I) to 20.4 days per cm, in bifocal tibial lengthening from 22.7 (group I) to 16.3d/cm (group II), in humeral lengthening – from 30.2 to 21.3 d/cm. In fact, it appears that the association of the external fixator of the Ilizarov type or TSF® with FIN allows to reduce the healing index significantly: in 12 of 16 compared categories the reduction of the index was from 20% to 40% or from 4.0 to 19.1 days per cm. In group I four cases of deep infection of soft tissues, 2 osteomyelitis, 21 fractures or deformities after frame removal were manifested. In group II – onlyone case of deformation after frame removal, absence of severe infectious complications, 8 cases of migration of the intramedullary wires. Discussion. FIN creates an elastic and resistant system during the lengthening. We even suggest that it stimulates the formation considering an apparent decrease of the healing index. On the other hand, the elasticity of nails prevents secondary fractures or deformations after frame removal. Conclusion. Combination of the circular EF and FIN in limb lengthening in children significantly decreases the duration of external fixation and the amount of severe infections and fractures

Purpose. The purpose of this study was to prospectively evaluate the rehabilitation outcome of children following operative and non-operative stabilisation of long bone fractures sustained in conjunction with an acquired brain injury (ABI). Materials and Methods. Between 1996 and 2002, children up to 16 years of age who were admitted to the Paediatric Intensive Care Unit (PICU) with an ABI and concomitant tibial or femoral shaft fractures were considered eligible for inclusion. Children who died or were unable to walk before the accident were excluded. All data relating to the sustained injuries, the duration of PICU inpatient stay, the fracture treatment and the functional outcome were collected prospectively. The severity of the injuries was assessed using the Injury Severity Score (ISS) and the Glasgow Coma Score (GCS). The duration of time was taken from admission to reaching rehabilitation milestones; the ability to sit, stand and walk was then assessed. Total duration of hospital inpatient stay and mobility on discharge were also recorded. Operative skeletal stabilisation included external or internal fixation, as well as flexible intramedullary nailing. Statistical analysis was performed using the Mann-Whitney U Test. Results. From 300 children admitted to the PICU for treatment of ABI, thirty-seven fulfilled the criteria for inclusion into the study. For both groups (operative vs nonoperative treatment) the mean age of patients was 9 years (range 1–15yrs) and the ISS, GCS scores and the mean stay in PICU were similar. There was a total of 21 femoral fractures (11 treated conservatively and 10 operatively) and 16 tibial fractures (7 conservatively and 9 operatively). Overall, the results showed a reduction in the mean time taken to reach all rehabilitation milestones following operative fracture stabilisation when compared to those treated non-operatively. The mean time to sitting was reduced from 27.1 days to 17.8. The mean time to standing was reduced from 50.1 to 35.6 and to walking, from 67.1 to 45.7 days. The Mann-Whitney U Test demonstrated a statistically significant reduced time to walk in the operatively treated group (p<0.05). Due to the small size of the sample group, significant statistical data for the other parameters measured was not evident. Conclusion. This study was specifically aimed at the short to medium term gains of operative treatment of tibial and femoral fractures in association with ABI. It has been shown that a co-ordinated rehabilitation programme plus operative stabilisation of children's tibial and femoral shaft fractures sustained in association with ABI, hastens rehabilitation, as it allowed aggressive rehabilitation programme to commence at a much earlier stage without risk of loss of fracture reduction

Purpose. Pediatric tibial shaft fractures (TSF) account for 15% of long bone fractures in children. Compartment syndrome (CS) is difficult to diagnose in children, often leading to disastrous outcomes. This study investigated the incidence of CS in TSF and its associated risk factors. Method. A detailed five-year retrospective chart review of TSF treated at a major pediatric hospital. CS was diagnosed clinically or by intra-compartment pressure. Multivariate logistic regression analysis tested age, gender, mechanism of injury, time to surgery, fracture type, and treatment intervention as possible risk factors for CS. Results. There were 216 TSF in 212 children (160 males, 52 females; mean age 13.6 years, range eight-18 years). One hundred and thirty-two (61%) fractures were treated with closed reduction and casting, 36 with external fixation, 21 with flexible intramedullary nails, and 27 with locked intramedullary nails. There were 23 cases of CS (10.6%). Multivariate predictors of CS included age 14 years and older (21/96 = 22%, p < 0.001) and motor vehicle accident (MVA) (12/57 = 21%, p = 0.002). Incidence of CS was 44% among patients 14 and older who sustained MVA (11 of 25). Gender, AO fracture type, time to surgery and surgical fixation were not predictive of CS. Conclusion. This is the first large study to report the incidence of CS from TSF in children. The incidence of 10.6% is higher than previously reported and much higher in patients 14 years of age and older and involved in an MVA. Surgeons should be especially aware and suspicious of CS in children with tibial shaft fractures who have these risk factors

Between 2005 and 2010 ten consecutive children with high-energy open diaphyseal tibial fractures were treated by early reduction and application of a programmable circular external fixator. They were all male with a mean age of 11.5 years (5.2 to 15.4), and they were followed for a mean of 34.5 months (6 to 77). Full weight-bearing was allowed immediately post-operatively. The mean time from application to removal of the frame was 16 weeks (12 to 21). The mean deformity following removal of the frame was 0.15° (0° to 1.5°) of coronal angulation, 0.2° (0° to 2°) sagittal angulation, 1.1 mm (0 to 10) coronal translation, and 0.5 mm (0 to 2) sagittal translation. All patients achieved consolidated bony union and satisfactory wound healing. There were no cases of delayed or nonunion, compartment syndrome or neurovascular injury. Four patients had a mild superficial pin site infection; all settled with a single course of oral antibiotics. No patient had a deep infection or re-fracture following removal of the frame. The time to union was comparable with, or better than, other published methods of stabilisation for these injuries. The stable fixator configuration not only facilitates management of the accompanying soft-tissue injury but enables anatomical post-injury alignment, which is important in view of the limited remodelling potential of the tibia in children aged > ten years. Where appropriate expertise exists, we recommend this technique for the management of high-energy open tibial fractures in children.

Statement of purpose of study: To determine how effective Flexible Intramedullary Nails are in treating tibial and femoral fractures in adolescents. Summary of Methods used: Retrospective review of consecutive adolescent patients treated over a seven year period with Flexible Intramedullary Nails for tibial and femoral fractures. Statement of Conclusion: We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures. Introduction Flexible intramedullary nails (FIN) are increasingly used in the management of paediatric tibial and femoral fractures. Recently, concerns have been raised regarding the use of FIN in older children. The aim of this study was to determine how effective FIN's are in treating tibial and femoral fractures in adolescents. Methods Hospital records were used to identify all patients aged 11 years or older under going FIN for tibial and femoral fractures between 2003 and 2009. Radiographs and case notes were reviewed to identify complications. Results 35 consecutive adolescent patients underwent FIN for tibial (n=21) and femoral fractures (n=15) with a mean age of 12.9 years. 2 femoral and 9 tibial fractures were open. Eight patients sustained multiple injuries. Mean radiographic follow up was 29 weeks. 60% (n=9) and 38% (n=9) of femoral and tibial fractures respectively malunited. Fracture severity was associated with increased malunion for both tibial and femoral fractures (P=0.046 and P=0.044 respectively). There were no cases of non-union. 2 femoral fractures took longer than 20 weeks to unite and 7 tibial fractures took longer than 16 weeks to unite. One patient developed post operative compartment syndrome, one patient developed deep infection and two patients were treated with post operative traction for loss of fracture position. Discussion Previous publications from multiple centres, including ours, have demonstrated excellent results of FIN for tibial and femoral fractures in the general paediatric population. However, concerns have recently been raised about the use of FIN in older, heavier children and with unstable fracture patterns. This is the first published series of adolescent patients undergoing FIN. We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures

Background. The aim of this study was to identify and quantify any benefits of early active treatment of paediatric femoral shaft fractures for patients, their families, and the hospital. Patients and methods. Our protocol (1999-2002) uses flexible intramedullary nails for children older than five, early hip spica (within one week of injury) for the under five year olds, and external fixation for polytrauma (Early Active Group[EAG], n = 25). Prior to this (1999-2002), treatment consisted of late application of a hip spica (3-4 weeks following injury) or inpatient traction (Traditional Group [TG], n = 41). Outcome measures were length of hospital stay, degree of malunion, knee and hip movements, and leg length discrepancy. The financial burden to the family including waged and non-waged time lost, transport, childminder, and other extra costs were estimated. Hospital costs including inpatient stay, theatre, and implant costs were analysed. Results. A 40% reduction in the incidence of femoral fractures over the six-year period was noted. Mean hospital stay was 29 and 10 nights (p<0.001); family costs were £1,243 and £968; and hospital costs were £10,831 and £4,291 per patient (p<0.005) in the TG and the EAG respectively. Parents in both groups preferred early discharge (86%-94%). In the EAG, 10 patients were short at 3 months (0.5 - 3 cm). None was short at 2 years. Eight children were long at 2 years. At 2 years, all had good clinical and functional results. There was no significant difference in the mal-union rate between the two groups. All the fractures united by three months. Five out of nine complications occurred in the EAG. Conclusion. The use of our early active treatment protocol has resulted in a significant reduction in hospital stay, costs to the families and the hospital

The purpose of the study was to establish an algorithm for the treatment of pathological fractures in children. Pathological fractures can compromise radiographic and histological diagnosis. The need for histological diagnosis and indications for surgical treatment are not clearly defined. We reviewed our Centre’s Tumour Registry records of children who presented over the past 7 years with a fracture as the first manifestation of primary bone pathology. There were 23 patients (average age 12 years and 2 months). There were 9 fractures through simple bone cysts, all treated conservatively initially. All patients were subsequently treated with needle biopsy and bone marrow injection. Three patients suffered refracture and underwent flexible intramedullary nail fixation. There were 5 cases of fibrous dysplasia. Histological diagnosis was obtained in all cases, followed by prophylactic intramedullary nailing in 3 patients. There were 2 patients with giant cell tumour, 3 with aneurysmal bone cyst and one with chondroblastoma. Histological diagnosis preceded curettage and grafting in all cases. Finally, there were 3 patients with Ewing’s sarcoma of the femur. One underwent palliative intramedullary nailing for extensive local disease. The second patient was treated conservatively initially. She subsequently underwent segmental resection and vascularised fibular graft. The third patient underwent internal fixation in another unit for what was considered to be a benign lesion. The histological diagnosis of Ewing’s sarcoma was based on intra-operative specimens. Definitive surgery required wide resection and prosthetic replacement. We recommend that primary fixation of pathological fractures should be avoided until histological diagnosis is obtained. All lesions should be appropriately imaged and biopsied if aggressive characteristics are present. However, if radiographic appearances are reassuringly benign, biopsy can be delayed until conservative fracture management is completed. Definitive treatment of benign lesions with protective intramedullary nailing or curettage and grafting can follow frozen section under the same anaesthetic