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

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

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