Femoral and tibial fractures

Femoral shaft fractures have a bimodal distribution with high energy injuries in young patients and an increasing incidence of osteoporotic fractures in elderly patients. Adult diaphyseal fractures are invariably managed operatively and the procedure most commonly performed is stabilisation with antegrade reamed intramedullary nailing. Retrograde nailing is also used for specific indications. Plating is still used for more distal fractures. External fixation and non-operative treatment by traction are seldom used now due to high risk of complications. Tibial shaft fractures are the most common long bone fracture and the most common open long bone fracture (21%). Reamed intramedullary nailing is the most common treatment for unstable fractures. Low energy undisplaced fractures can be treated non-operatively in a cast or brace. Plating is not often used for diaphyseal injuries but is useful for metaphyseal fractures. External fixation is still commonly used for some severe open injuries or to correct deformity. Complications of femoral and tibial fractures include nonunion, malunion and infection in association with open fractures. Compartment syndrome complicates 2-10% of tibial fractures. For closed fractures the incidence of all of these complications should be less than 5%. Open fractures have a greater risk of complication which is generally proportional to the energy of the injury.     

Management of pediatric femoral shaft fractures

Femoral shaft fractures are the most common major pediatric injuries managed by the orthopaedic surgeon. Management is influenced by associated injuries or multiple trauma, fracture personality, age, family issues, and cost. In addition, child abuse should be considered in a young child with a femoral fracture. Nonsurgical management, usually with early spica cast application, is preferred in younger children. Surgery is common for the school-age child and for patients with high-energy trauma. In the older child, traction followed by casting, external fixation, flexible intramedullary nails, and plate fixation have specific indications. The skeletally mature teenager is treated with rigid intramedullary fixation. Potential complications of treatment include shortening, angular and rotational deformity, delayed union, nonunion, compartment syndrome, overgrowth, infection, skin problems, and scarring. Risks of surgical management include refracture after external fixator or plate removal, osteonecrosis after rigid antegrade intramedullary nail fixation, and soft-tissue irritation caused by the ends of flexible nails.     

Stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails (a technique paper).

The indications for surgical stabilization of a pediatric diaphyseal femur fracture are expanding. Children with multiple system injuries, a head injury, and/or multiple fractures have fewer local and distant complications if the femur fracture is treated operatively. Other indications include a pathological fracture in osteoporotic bone, a fracture in a child with a preexisting condition that prevents the application of a spica cast, a child older than 10 years of age, or a child less than 10 years of age who cannot be kept adequately aligned using conventional (traction/casting) methods of fracture management. Here we describe a technique of stabilizing pediatric diaphyseal femur fractures using flexible intramedullary nails (Ender). This technique can be used in children of all ages and with all patterns of diaphyseal fractures.     

Femoral shaft fractures in children

Femoral shaft fractures are the commonest diaphyseal fractures of childhood after those of the radial and ulnar shaft and the tibial shaft. Common mechanisms include falls, particularly from playground equipment, motor vehicle accidents and sporting injuries. Unlike in adults, femoral shaft fractures are commonly isolated injuries in children. In infants, they may be due to non-accidental injury. Treatment of femoral shaft fractures varies with the age and size of children, associated injuries and local practice. Current modalities used for the treatment of femoral shaft fractures include various forms of traction, immediate and late spica casting, elastic nailing, external fixation, plate fixation, and conventional intramedullary nailing for older children and adolescents. All these forms of treatment have been reported as being successful in cohort studies. Very few comparative studies exist. The main current controversies are the age at which elastic nailing becomes appropriate instead of conservative management, and secondly, the treatment of the older, heavier child for whom elastic nails may not be appropriate. Familiarity with several methods of femoral shaft stabilisation is appropriate. The major determinant in the choice of treatment is cultural.     

The incidence of compartment syndrome after flexible nailing of pediatric tibial shaft fractures

Purpose  

Pediatric tibial shaft fractures are common injuries encountered by the orthopaedic surgeon. Flexible intramedullary nailing has become popular for pediatric patients with tibial shaft fractures that require operative fixation. The purpose of our study was to evaluate the incidence of, and the risk factors for, compartment syndrome (CS) after flexible intramedullary nailing of these injuries.     

Treatment of unstable tibial shaft fractures by closed intramedullary nailing with flexible (Ender-type) pins.

Eighty patients with unstable tibial diaphyseal fractures were treated by closed intramedullary nailing with Ender-type flexible pins. The majority of injuries occurred from falling while snow skiing. Sixty-six fractures were closed and 14 were open. Fifty-eight fractures involved the distal, 21 fractures the middle, and one fracture the proximal one third of the tibial shaft. The average time to roentgenographic union was 15.5 weeks (range, ten to 34 weeks) for closed and open Grade I and II fractures. The time to union in Grade III fractures was 50 weeks (range, 36-64 weeks). There were two nonunions and two delayed unions. Both nonunions occurred in Grade IIIA open shaft fractures. Intramedullary stabilization with flexible, Ender-type pins provides good control of unstable tibial shaft fractures. The use of pins with a smaller diameter (3.5 or 4 mm) allows the surgeon to place more pins across the fracture site. The use of multiple pins and packing the intramedullary canal may provide better rotational stability. The use of Ender-type pins for fixation of Type IIIA open tibial shaft fractures is contraindicated.     

Diametaphysäre Unterschenkelfraktur

Fractures of the lower leg are the most common shaft fracture injury in children and adolescents. The incidence is reported to be 5.8% in the literature. Conservative treatment is indicated in nondisplaced fractures of the isolated tibial shaft, while surgery is recommended in cases of unstable fractures of the lower leg. Elastic stable intramedullary nailing (ESIN), external fixation, or plate osteosynthesis are common implants for stabilization. As a complication, compartment syndrome must be considered because it occurs more commonly in children undergoing surgery. In addition, differences in leg length can occur. Overall the prognosis is good if treated correctly.     

Pediatric fractures of the forearm

Forearm fractures are common injuries in childhood. There are a number of important principles that should be followed to achieve the ideal goal of fracture healing without deformity or dysfunction. I will review the general principles, classifications, diagnosis, treatment, and complications of pediatric forearm fractures, including some specific injuries such as Monteggia fractures, Galeazzi injuries, and open fractures. The basic principle is to accurately align the fracture fragments and to maintain this position until the fracture is united. Forearm fractures in children can be treated differently from adult fractures because of continuing growth in both bones (radius and ulna) after the fracture has healed. As long as the physes are open, remodeling can occur. However, generally it is thought that rotational deformity does not remodel. Undisplaced fractures may be treated in a cast until the fracture site is no longer painful. Most displaced fractures of the forearm are best maintained in a long arm cast. However, redisplacement occurs in 7 to 13% of cases, usually within 2 weeks of injury. Unstable metaphyseal fractures should be percutaneously pinned. Unstable diaphyseal fractures can be stabilized by intramedullary fixation of the radius and ulna. If none of these techniques is helpful, plate and screw fixation is the best choice.     

预置阻挡钉在治疗胫骨螺旋形骨折合并后踝骨折中的作用

目的 探讨预置阻挡钉在治疗胫骨中下1/3 螺旋形骨折合并后踝骨折中的作用.方法 回顾性分析2018 年5月至2020 年6 月收治的24 例胫骨中下1/3 螺旋形骨折合并后踝骨折患者临床资料.所有患者均采用预置阻挡钉技术,并进行髓内钉及空心钉内固定治疗.术后记录胫骨正位 X 线片上冠状面力线(胫骨远端外侧角)、膝关节疼...     

Fractures of the femur and tibial shaft

Fractures of the femoral and tibial shaft are common injuries. They exhibit a bimodal age distribution and are frequently associated with other injuries. Their fracture patterns vary, and so are managed using a range of treatment options.The first priority is to check that there are no life-threatening injuries or acute complications associated with the injuries sustained. Once these are ruled out, the orthopaedic team can begin planning the treatment option best suited to the fracture and patient. For femoral fractures this usually involves intramedullary nailing, or plating, across the fracture site. Conservative and mono-lateral external fixation of the femur is now considered inadvisable because of the higher risk of complications and decreased rehabilitation potential. For tibial fractures the options are either conservative management, in a non-weight-bearing cast, or intramedullary nailing or plating. External fixation remains a useful modality in severe deformity or open fractures of the tibia. Complications commonly associated with both these fractures include venous thromboembolism, infection, compartment syndrome, fat embolism, vascular injury and mal- or non-union of bone.     

可吸收髓内针在四肢长骨干骨折中的应用

目的观察可吸收髓内针在四肢长骨干骨折中应用的疗效。方法23例四肢长骨干骨折应用可吸收髓内针内固定。其中,胫骨干骨折18例,肱骨干骨折5例;胫骨骨折中粉碎性骨折8例。结果随访8~31个月。术后切口均Ⅰ期愈合,无切口感染及肿胀积液,无骨髓炎、畸形愈合及骨不连接发生,无毒性反应及副作用,患肢功能良好。结论可吸收髓内针是治疗四肢长骨干骨折较理想的一种内固定方法。     

Posterior malleolar fracture is often associated with spiral tibial diaphyseal fracture: a retrospective study

BACKGROUND: It is known that posterior malleolar fracture is often associated with tibial diaphyseal fractures. However, in literature there are very few studies on tibial shaft fractures with respect to posterior malleolus fragment. We hypothesized that the incidence of posterior malleolar fracture is higher than in previous studies. METHODS: A total of 74 closed tibial shaft fractures were treated with intramedullary nailing in Turku University Central Hospital between January 1994 and December 1998. There were 55 men and 19 women, with a mean age of 39 years (range, 16 to 58 years). Two cases were excluded and 72 tibial shaft fractures were analyzed retrospectively. RESULTS: Posterior malleolar fracture was observed in 18 cases (25.0%). Only 10 were observed preoperatively in plain films, seven were detected postoperatively and one was not detected at all during the treatment. Retrospectively, all 18 posterior malleolar fractures were detectable in preoperative plain films. CONCLUSION: A fracture of the posterior malleolus was involved in every fourth tibial diaphyseal fracture. The fractures of the posterior malleolus were always detected in preoperative plain films and should be suspected, especially in cases of low-energy spiral distal tibial diaphyseal fractures. We recommend additional plain films to be taken at the ankle region to better visualize these fractures.     

Fractures of the fifth metatarsal in children and adolescents

OBJECTIVE: Fractures of the fifth metatarsal are the most common metatarsal fractures in children. Their treatment is based on the adult literature. The purpose of our study was to identify the different types of fifth metatarsal fractures, to determine the mean time to healing, and to examine whether current adult recommendations can be extrapolated to children and adolescents. METHODS: A total of 103 patients met the inclusion criteria. The fractures were classified according to location. Type I represented an apophyseal injury. Type II represented tubercle fractures with intra-articular extension. Type III injuries represented Jones fracture. Metatarsal neck and shaft fractures were included separately. RESULTS: Apophyseal fractures did well with a short-leg walking cast for 3 to 6 weeks. Displaced intraarticular fractures had a significant delay in healing versus nondisplaced ones. Jones fractures had delays in healing if not treated surgically. Neck and shaft fractures did well with casting. CONCLUSIONS: Most fractures of the fifth metatarsal in the pediatric population do well clinically after a course of walking cast, unless the fracture is an intra-articular displaced fracture type or the fracture occurs in the proximal diaphyseal area. Fixation of Jones fractures in active adolescents should be considered to allow faster return to regular activities and prevent refracture. We recommend non-weight bearing casts for all angulated or displaced intra-articular injuries to avoid delays in healing and angulation. From our series, it is evident that most pediatric fifth metatarsal fractures behave as those found in adults and can be treated similarly.     

Intramedullary fixation for pediatric unstable forearm fractures

Forty-nine children with diaphyseal both-bone forearm fractures were treated with either both-bone intramedullary wire fixation (24), single ulnar intramedullary wire fixation (22), or single radial intramedullary wire fixation (3). Six fractures were open and 43 were closed. A limited open approach to one or both bones was necessary for insertion of the intramedullary wire in 10 of 43 closed fractures. All both-bone and single radial intramedullary wire fixations healed with less than 5 degrees angulation. Progressive reangulation of the nonfixed radial fracture after an initial satisfactory reduction was seen in seven of the 22 fractures treated with single ulnar intramedullary wire fixation. In four patients, the reangulation was controlled by a change of cast and molding of the fracture and was between 8 degrees and 12 degrees at union. In two other patients a second operative procedure was required to reduce and internally fix the radius. One fracture healed with a radial angulation of 25 degrees. Three fractures in older patients showed late reangulation after early removal of intramedullary wires at 5 weeks. The results of the current study suggest that the radius and ulna should be stabilized with intramedullary wires and that the wires should be buried to reduce the need for early removal.     

Complications of rigid intramedullary rodding of femoral shaft fractures in children

BACKGROUND: Intramedullary rodding of femoral shaft fractures has been frequently performed in adults, but until recently rarely in children. It was the purpose of this study to investigate the experience with this treatment method at a pediatric trauma center. METHODS: From 1987 to 1998, 54 children were treated for traumatic femoral fractures with intramedullary rods at a major pediatric trauma center. The average age was 15 years 3 months, ranging between 11 years 4 months and 17 years 11 months. The average follow-up was 5 years 3 months, ranging from 20 months to 10 years 1 month. RESULTS: All of the fractures occurred secondary to trauma and the most common anatomic fracture site was the femoral midshaft. Complications encountered included 8 instances of minor limb length discrepancy, 11 instances of discomfort because of rod prominence, 1 case of avascular necrosis of the femoral head, 2 instances of heterotopic ossification over the rod tip, 1 broken rod, and 3 cases that demonstrated decreased external rotation of the affected limb. One child developed osteomyelitis after intramedullary rodding for a fracture previously treated with external fixation. There were no cases of surgically induced nonunion or malunion and only one delayed union secondary to infection. CONCLUSION: Results of this series demonstrate intramedullary rodding to be an effective treatment modality for femoral fractures in skeletally mature children. In children with open femoral physes, rigid rodding should be avoided because of the small but serious occurrence of avascular necrosis of the femoral head. Intramedullary rodding is not recommended in children initially treated with external fixation because of the increased risk of infection.     

Simultaneous ipsilateral diaphyseal fractures of the femur and tibia: treatment and complications

We present our experience of intramedullary nailing (IM) and external fixation in the treatment of 54 patients with ipsilateral diaphyseal fractures of the femur and tibia. Eight femoral and 24 tibial fractures were open. They were classified into three groups: IM nailing of both fractures (group A, 19 patients); IM nailing of the femoral and external fixation of the tibial fracture (group B, eight patients); and external fixation of both fractures (group C, 27 patients). In group C (which included all but one grade III open fracture), two patients died and four underwent amputation. Femoral fractures treated with external fixation had significantly more complications and reoperations than those treated with IM nailing. In tibial fractures this difference was also present but not statistically significant. We believe that IM nailing is the method of choice for femoral fractures and is preferable for tibial fractures, with the exception probably of grade III B and C open injuries.     

Interlocking intramedullary nailing for ipsilateral fractures of the femoral shaft and distal part of the femur.

A review of the data on 684 fractures of the femur that had been treated with intramedullary nailing led to the identification of twenty-three patients who had had a fracture of the shaft of the femur with an accompanying ipsilateral supracondylar fracture (twelve patients, group I) or a concomitant ipsilateral intercondylar fracture (eleven patients, group II). The group-I fractures had been treated with interlocking nailing without supplemental fixation. In group II, ten fractures were stabilized with interlocking nailing and supplemental screw fixation and one, with interlocking nailing and a supplemental plate and screws. The average time to union for all fractures was nineteen weeks (range, twelve to thirty-six weeks), and the average duration of clinical and radiographic follow-up was thirty months (range, nine to fifty-nine months). In group I, alignment of the femur was within 5 degrees of normal in ten of the twelve fractures. In group II, seven intra-articular fractures healed in anatomical alignment, three had slight articular displacement (1.0 to 3.0 millimeters), and one had displacement of more than 3.0 millimeters. The average range of motion of the knee at the most recent follow-up was 0 to 120 degrees in group I and 0 to 115 degrees in group II. Two patients (both in group II) needed a reoperation for a previously unrecognized fracture of a femoral condyle in the coronal plane; post-traumatic arthritis developed in both. No patient in either group had loss of fixation or failure of the implant. We concluded that ipsilateral diaphyseal, supracondylar, and intercondylar fractures of the femur can be adequately stabilized with interlocking nailing and supplemental intercondylar screw fixation. The presence of a fracture in the coronal plane of a femoral condyle (AO type-B3 and type-C3 injuries) is a relative contraindication to the use of this technique.     

扩髓带锁髓内钉治疗股骨、胫骨干骨折不愈合、延迟愈合

目的　总结使用扩髓带锁髓内钉治疗股骨、胫骨干骨骨折不愈合、延迟愈合的临床经验。方法　回顾自 1999年 4月～2 0 0 1年 6月使用扩髓带锁髓内钉治疗股骨干、胫骨干骨折不愈合、延迟愈合病人 2 1例 ,其中股骨 8例 ,胫骨 13例 ,钢板固定术后 ,股骨 3例 ,胫骨 6例。普通髓内针股骨 5例。外固定架胫骨 2例。石膏固定胫骨 3例 ,骨牵引股骨 2例。均采用有限切口切开复位顺行扩髓 ,静力锁定加植骨术。结果　随访半年以上 18例 ,骨折均愈合 ,临近关节功能达正常。无感染、断钉等并发症。结论　采用有限切口切开复位、扩髓、静力锁定治疗股骨、胫骨干骨折不愈合、延迟愈合 ,具有骨折稳定性可靠、有利于骨折愈合和早期关节活动的优点 ,是治疗股骨、胫骨干骨折不愈合、延迟愈合的有效方法之一。     

Distal Tibial Fractures: Intramedullary Nailing

The tibia is an exposed bone with vulnerable soft tissue coverage and is therefore predisposed to local soft tissue problems and delayed bone healing. The objective in distal tibial fracture treatment is to achieve stable fixation patterns with a minimum of soft-tissue affection. Thus, the risk of soft tissue breakdown and bone healing complications is more likely related to open reduction and plating. Percutaneous, minimally invasive intramedullary nailing is a proven fixation mode for fracture stabilization in tibial shaft fractures. Anticipating the pitfalls, intramedullary nailing meets the requirements of the method of choice in distal tibial fracture fixation. In conclusion, intramedullary nailing of distal tibial fractures is a reliable method of fixation, possessing the advantages of closed reduction and symmetric fracture stabilization of an area with a delicate soft tissue situation, but prospective randomized trials are needed to compare modern intramedullary fracture fixation with modern plate fixation in distal tibial fractures.     

Kindliche Oberschenkelschaftbrüche

The femoral shaft is the second most frequent fracture location in the lower extremity in children. Diagnosis of a femoral shaft fracture in a child should not obstruct the detection and treatment of concomitant life-threatening injuries and should be carried out quickly. X-ray examination of the femur must include the adjacent joints. Since growth is still ongoing in the child's skeleton, fracture healing proceeds in quite a different manner from that in an adult, and substantial alterations in leg length frequently emerge. Displacement by not more than the shaft diameter, shortening resulting from the fracture, rotation deformity and varus deformity can usually be revised with no major problems in children who are expected to go on growing for longer than 2 years. Valgus malposition and malalignment in ante- and recurvation are more difficult to compensate. Dislocated femoral shaft fractures should be stabilized surgically in pediatric patients. Dynamic intramedullary dynamic nailing is always the therapy of choice if three-point stabilization of the with flexible titamium screws can be guaranteed. When this is not possible we recommend the application of an external fixator. In undislocated fractures immobilization of the hip and leg in a cast is a reasonable alternative to surgery.