The April 2024 Children’s orthopaedics Roundup³⁶⁰ looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study.

The February 2024 Children’s orthopaedics Roundup. 360. looks at: Hip impingement after in situ pinning causes decreased flexion and forced external rotation in flexion on 3D-CT; Triplane ankle fracture patterns in paediatric patients; Improved forearm rotation even after early conversion to below-elbow; Selective dorsal rhizotomy and cerebral palsy (CP) hip displacement; Abduction bracing following anterior open reduction for developmental dysplasia of the hip does not improve residual dysplasia or reduce secondary surgery; 40% risk of later total hip arthroplasty for in situ slipped capital femoral epiphysis (SCFE) pinning; Does brace treatment following closed reduction of developmental dysplasia of the hip improve acetabular coverage?; Waterproof hip spica casts for paediatric femur fractures

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.

Paediatric femoral fractures are a common result of significant trauma, and always require intervention. Hip spica casting, traction, and surgical fixation can all be used to treat these fractures. This variety in treatment options leads to a vast potential for variability in management decisions among surgeons and has prevented effective comparative studies to show which treatment methods provide optimal outcomes for patients. The purpose of this study was to identify practice variability in management and follow-up and assess patient outcomes to aid in the development of a comprehensive, prospective, evidence-based pathway for the management of paediatric femoral fractures. A retrospective chart review was performed of all patients treated surgically for isolated femoral fractures during a six year period at a single tertiary care paediatric centre. Patients were identified from a surgical database and were included if there was no pre-existing pathology and no history of previous femoral fracture. Demographic data, operative details, post-operative management, and clinical outcomes were collected. Radiographic images and reports were analyzed to determine fracture classification and imaging parameters. Variability in treatment among eight surgeons was assessed, including number of follow-up appointments and length of follow-up. Patient demographics and follow up measures were summarised for each surgeon and between surgeon variability was assessed with linear models. In total, 138 femoral fractures in 134 patients (101 male, 33 female) were included in analysis. Of these patients, 55 had right femoral fractures, 76 left, and three bilateral (one bilateral patient had three distinct femoral fractures). Of 138 total fractures, 131 were of the diaphysis of the femur. 14 patients sought initial surgical treatment at our institution but received follow-up management elsewhere. Across all patients, median follow-up time was 32.8 weeks (0–201.4) with a median of three follow-up visits (0–26) in that period. Mean number of follow-up clinic visits ranged from 3 to 4.8 among surgeons, and mean length of follow-up ranged from 31.8 to 62.3 weeks. No significant differences in follow-up between surgeons were found, but small sample sizes are a likely contributing factor. Summary statistics show large ranges in most variables and differences in patient demographics between surgeon groups. The large ranges in follow-up time and visit number suggest a lack of consensus on optimal management for paediatric femoral fractures. Further prospective study examining long-term functional and quality of life outcomes will be required to identify and develop optimized management guidelines

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.

The December 2015 Children’s orthopaedics Roundup. 360 . 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

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.

Cite this article: Bone Joint J 2015;97-B:558–63.

The June 2014 Children’s orthopaedics Roundup³⁶⁰ looks at: plaster wedging in paediatric forearm fractures; the medial approach for DDH; Ponseti – but not as he knew it?; Salter osteotomy more accurate than Pemberton in DDH; is the open paediatric fracture an emergency?; bang up-to-date with femoral external fixation; indomethacin, heterotopic ossification and cerebral palsy hips; lengthening nails for congenital femoral deformities, and is MRI the answer to imaging of the physis?

Elastic stable intramedullary nailing (ESIN) is generally acknowledged to be the treatment of choice for displaced diaphyseal femoral fractures in children over the age of three years, although complication rates of up to 50% are described. Pre-bending the nails is recommended, but there are no published data to support this. Using synthetic bones and a standardised simulated fracture, we performed biomechanical testing to determine the influence on the stability of the fracture of pre-bending the nails before implantation. Standard ESIN was performed on 24 synthetic femoral models with a spiral fracture. In eight cases the nails were inserted without any pre-bending, in a further eight cases they were pre-bent to 30° and in the last group of eight cases they were pre-bent to 60°. Mechanical testing revealed that pre-bending to 60° produced a significant increase in the stiffness or stability of the fracture. Pre-bending to 60° showed a significant positive influence on the stiffness compared with unbent nails. Pre-bending to 30° improved stiffness only slightly.

These findings validate the recommendations for pre-bending, but the degree of pre-bend should exceed 30°. Adopting higher degrees of pre-bending should improve stability in spiral fractures and reduce the complications of varus deformity and shortening.

Purpose: Femur fractures in children have a significant impact on families and the hospital system in Canada. There are several methods for treating femur fractures in children. The purpose of this study was to determine which of two techniques: Flexible Femoral Nailing (FFN) or Trochanteric Antegrade Nail (TAN), are the most safe and efficacious. Method: Hospital charts for all paediatric femur fracture patients between 1984 and 2006 treated with either FFN or TAN were reviewed. Demographic, clinical, radiographic and hospital stay data were collected and analyzed. Results: Ninety-seven children (100 fractures) were reviewed. The average age of patients was 11.9 years (SD = 4.4). Fifty-two fractures were treated with FFN and 48 fractures were treated with TAN. No serious complications were encountered in either group, including AVN. Minor complications in the FFN group included three patients with mal-alignment, and one with shortening of the limb. Two patients in the TAN group had shortening of the fractured limb. No radiographic differences were noted. The median length of stay for patients treated with FFN was 3 days (IQR = 2) and for patients treated with TAN was 3 days (IQR = 2). Overall, there were no significant differences in the clinical findings (including complications), radiographic evaluations, or length of stay between FFN and TAN cohorts. The only significant difference between the groups was length of surgical time (p value < 0.001). Conclusion: TAN is as safe and efficacious a treatment as FFN but requires addition operating room time, and hence hospital resources

The need for operative fixation of paediatric femoral fractures is increasingly being recognised in the present decade. The conventional traction and casting method for management of paediatric femoral fractures is giving way for the operative stabilisation of the fracture. We conducted a prospective study on 25 pediatric patients age group 6–14 years with diaphyseal femoral fractures, stabilised with two titanium nails of same size. Titanium nails were inserted through distal metaphyseal area 1 inch above the physis in a retrograde manner. Patients were followed up clinically and radiologically for one year.No patient was lost in the followup. Overall good results were reported with the use of TENs with minimal complications. Hospital time averaged 4.26 days in the series. All the fractures healed with an average time to union of 2.96 weeks. Return to school was early with an average of 7.8 weeks. Shortening was reported in two cases due to angulation at the fracture site. There were no delayed union or infection. The soft tissue discomfort near the knee produced by the nails ends was the most common problem encountered and thence cutting the nail ends closer to the bone is important. 5 nails had to be removed ssssubsequently after the bony union due to this problem. With proper operative technique and aftercare TENs may prove to be an ideal implant for pediatric femoral fracture fixation in the coming times

Purpose: To determine the epidemiology of femoral fractures in children and their associated injuries. Patients and methods: We reviewed 475 consecutive children admitted over a seven-year period (1992–1999) to a university hospital. Such details were recorded and analysed as – mechanism of injury, ISS, GCS, ICU stay, total hospital stay, operations performed, presence or absence of femoral fracture, complications and mortality.

Results: Out of 475 children admitted, 57 had a femoral fracture (12%). 14 were girls and 43 were boys. The mean age was 5.1 (range 1–14) and the mean ISS was 6.9 (4–36). The mean GCS was 14 (range 5–15).

The commonest cause of injury was a fall from a height 21/57 (37%) followed by road traffic accidents 20/57 (35%), 11 cases were pedestrians. 6 cases were recorded as non-accidental injuries. 8 children underwent operative treatment whereas the rest were treated conservatively. In 36 children the femoral fracture was an isolated injury. The remaining 21 (37%) had 2 or more injuries. The most common associated injury was a head injury of varying severity 10 (50%) followed by fracture tibia 7 (33%) followed by fracture pelvis 4 (19%). Other associated injuries included a splenic laceration, one pancreatic injury, 3 humerus fractures and 3 forearm fractures. None of the children sustained a chest or spinal injury. The mean hospital stay was 22 days (1–67). 4 children were admitted to the intensive care unit (2 had head injuries) and the mean ICU stay was 3 days (2–5). There was no mortality in these series. Two children underwent fasciotomies for tibial compartment syndrome.

Conclusion: The incidence of associated injuries in children with femoral fractures appears to be 35% with head injury being the commonest. The overall prognosis is favourable as seen in these series of patients with nil mortality.