Comparison of compression plate and flexible intramedullary nail fixation in pediatric femoral shaft fractures

The purpose of this study was to compare the results of compression plating and flexible intramedullary nailing for pediatric femoral shaft fractures. Thirty-eight consecutive patients with 40 femoral shaft fractures were evaluated. Twenty-two femoral segments were treated with a compression plate and 18 femoral segments were treated with flexible intramedullary nailing. The time to healing, operation time and complications were evaluated. The average operation time was statistically significantly shorter in the nailing group (P=0.039). Four implant failures occurred in the compression plate group whereas one non-union was observed in the flexible nailing group. Flexible intramedullary nailing seems to provide a high union rate with a shorter operation time when compared with plate fixation.     

股骨干骨折接骨板或髓内针固定的局部并发症

目的 探讨股骨干骨折局部并发症发生的影响因素,并比较接骨板和髓内针固定方法在并发症方面的差异。方法 对我院１９８５－１９９４年间３２５例经内固定治疗的股骨干骨折进行分析。结果 ７２例发生局部并发症,发生率为２２％,其中髓内针组４６例;接骨板组２６例。结论髓内针固定股骨干骨折较接骨板有明显的优势,但在股骨下段,粗隆下肌折应用接骨板是较好的选择。     

Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients)

OBJECTIVES: The timing of definitive fixation for major fractures in patients with multiple injuries is controversial. To address this gap, we randomized patients with blunt multiple injuries to either initial definitive stabilization of the femur shaft with an intramedullary nail or an external fixateur with later conversion to an intermedullary nail and documented the postoperative clinical condition. METHODS: Multiply injured patients with femoral shaft fractures were randomized to either initial (<24 hours) intramedullary femoral nailing or external fixation and later conversion to an intramedullary nail. Inclusion: New Injury Severity Score >16 points, or 3 fractures and Abbreviated Injury Scale score > or =2 points and another injury (Abbreviated Injury Scale score > or =2 points), and age 18 to 65 years. Exclusion: patients in unstable or critical condition. Patients were graded as stable or borderline (increased risk of systemic complications). OUTCOMES:: Incidence of acute lung injuries. RESULTS: Ten European Centers, 165 patients, mean age 32.7 +/- 11.7 years. Group intramedullary nailing, n = 94; group external fixation, n = 71. Preoperatively, 121 patients were stable and 44 patients were in borderline condition. After adjusting for differences in initial injury severity between the 2 treatment groups, the odds of developing acute lung injury were 6.69 times greater in borderline patients who underwent intramedullary nailing in comparison with those who underwent external fixation, P < 0.05. CONCLUSION: Intramedullary stabilization of the femur fracture can affect the outcome in patients with multiple injuries. In stable patients, primary femoral nailing is associated with shorter ventilation time. In borderline patients, it is associated with a higher incidence of lung dysfunctions when compared with those who underwent external fixation and later conversion to intermedullary nail. Therefore, the preoperative condition should be when deciding on the type of initial fixation to perform in patients with multiple blunt injuries.     

Ipsilateral femoral neck,shaft, and supracondylar fractures: a case report

Ipsilateral femoral neck, shaft, and supracondylar fractures are rare injuries. This fracture pattern is difficult to treat, but no detailed cases were found in the English literature. The authors report a case of this unusual combination successfully managed by retrograde intramedullary nailing and screw fixation.     

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.     

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.     

Intramedullary nailing combined with cerclage wiring in the treatment of fractures of the femoral shaft

One hundred sixty-seven femoral shaft fractures were treated with open intramedullary nailing and cerclage wires. Complications requiring surgical reintervention developed in 11 patients (6.6%). Delayed union or nonunion in five patients (3%), deep infection in four patients (2.4%), or unstable fixation in two patients (1.2%) required one or more additional procedures to achieve union. The time to weight-bearing averaged 32 days in patients with isolated injuries and 62 days in patients with associated injuries. One hundred forty-five patients were followed until fracture union occurred. Rotational malalignment in one patient, angulation of 10 degrees or more in two patients, and limb shortening of more than 2 cm in two patients were noted. Loss of hip or knee motion in excess of 20 degrees developed in 15 patients and was always associated with injuries of the pelvis or ipsilateral lower leg. Intramedullary nailing and cerclage wiring significantly expands the indication for intramedullary fixation of fractures of the femoral shaft.     

Outcome of intramedullary nail for fixation of osteoporotic femoral shaft fractures in the elderly above 60

IntroductionIntramedullary nailing is an acceptable treatment option for femoral shaft fracture in young patients but not extensively studied in the elderly with osteoporotic fractures. Plate fixation for osteoporotic femoral shaft fractures have a high rate of complications and delayed healing time, and the most acceptable treatment is intramedullary nailing. This study evaluated the healing time and incidence of complications in osteoporotic femoral shaft fractures after intramedullary nailing.Patients &MethodsThis was a retrospective study that included 16 patients above 60 years old with osteoporotic femoral shaft fractures operated between January 2015 and December 2018. Patients with metastatic fractures or with atypical fractures were excluded. Thirteen patients had low-energy injuries such as a simple fall from standing height or lower and twisting injuries. The remaining 3 patients sustained high-energy-mechanism of injury. No patient received bisphosphonate except 2 patients received oral bisphosphonate for a period of 6 and 8 months, respectively.ResultsSixteen patients (12 females and 4 males) with mean age 69.5 ± 3.7 presented with femoral shaft fracture were operated with intramedullary nail, 10 patients were fixed with trochanteric entry nails with proximal neck screws, and 6 patients were fixed with piriformis entry nails. In 9 patients, closed reduction of fracture was achieved while 7 patients required open reduction, of which 5 fracture required cerclage wire addition. The mean bone healing time was 5.35±1.2 months. Intraoperative extension of femoral fractures during intramedullary nail insertion was observed in two cases that required open reduction and addition of cerclage wires around the fracture. The overall incidence of complications was 18.7%.ConclusionsIntramedullary nailing for osteoporotic femoral shaft fracture is a good acceptable option in elderly patients with reasonable healing time with no major complications.     

钢板加异体骨板固定治疗股骨干骨折髓内钉固定术后骨折不愈合

目的:探讨采用钢板加对侧异体骨板固定治疗股骨干骨折交锁髓内钉固定术后骨折不愈合的临床疗效.方法:分析自2006年2月至2013年6月21例股骨干骨折髓内钉固定术后不愈合患者采用钢板加对侧异体骨板固定治疗,男12例,女9例;年龄18～62岁,平均34.8岁.骨折不愈合时间9～18个月,平均12.8个月.术后采用Merchan标准评定临床疗效.结果:21例患者伤口均Ⅰ期愈合,无感染、内固定物断裂、脂肪栓塞、旋转畸形及明显的短缩畸形等并发症.术后随访8～24个月,平均13.2个月.19例患者术后达到骨性愈合,平均愈合时间为6.2个月(4～9个月),2例出现骨折延迟愈合,经7～13个月观察获得骨性愈合.术后1年膝关节功能按Merchan标准评定:优13例,良6例,差2例.结论:应用钢板加对侧异体骨板固定治疗股骨干骨折髓内钉固定术后骨折不愈合具有治愈率高,并发症少,术后功能恢复良好的特点,能够提高骨折稳定性及促进骨痂生长.     

附加钢板联合断端清理去皮质化植骨治疗股骨干骨折髓内钉术后无菌性骨不连

目的探讨附加钢板联合断端清理去皮质化植骨治疗髓内钉术后无菌性骨不连的临床疗效。方法回顾性分析2013年1月至2017年8月期间山东大学齐鲁医院急诊外科收治的40例股骨干骨折髓内钉治疗后无菌性骨不连的患者资料。所有患者均采用骨折断端清理、去皮质化、取自体髂骨植骨及附加单皮质锁定钢板治疗。术后随访观察切口愈合、疼痛、关节功能及骨折愈合情况等指标。结果所有患者术后均获得随访,平均随访时间为15(12~18)个月。治疗效果优良率100%(优37例,良3例)。所有患者下地负重行走时主观疼痛症状消失,患肢功能恢复良好,均无切口感染和内固定物疲劳断裂发生。所有患者疼痛视觉模拟评分由术前(6.0±1.1)分降至术后末次随访时(2.0±1.3)分(P<0.05)。末次随访时患者均获得骨性愈合,平均愈合时间8.5(5.5~14.5)个月。经X线或CT证实,均未发现螺钉及钢板松动断裂及感染等并发症。结论附加钢板联合断端清理去皮质化植骨治疗股骨干骨折髓内钉固定术后无菌性骨不连疗效确切、可靠,是一种有效的治疗股骨干无菌性骨不连的手术方式。     

交锁髓内钉治疗股骨干骨折术后感染和骨吸收的处理

目的 探讨交锁髓内钉治疗股骨干骨折术后感染及骨吸收的治疗方法。方法股骨十骨折交锁髓内钉固定术后感染及骨吸收13例,术后感染平均14．5个月。第一期拔除髓内钉、彻底清创、外同定支架固定,第二期植骨、抗感染;术后膝关节功能锻炼。结果随访平均4．2年。1年后骨折和感染均治愈,随访期内均无复发。结论合理的二期手术,是治疗交锁髓内钉固定股骨干骨折术后感染及骨吸收的可行方法。     

The influence of body injuries on bone union of femoral shaft fractures treated by different operative methods]

Femoral shaft fracture is very often main musculo-skeletal injury in polytrauma patient. We analysed bone union of femoral shaft fractures treated by different operative open methods--AO plate osteosynthesis, Zespol method and open intramedullary nailing and by closed intramedullary nailing, in patients with concomitant body injuries. We compared patients operated by open methods without complications with the group demanding fracture reoperation. We found out no statistical correlation between the frequency of local complications demanding reoperation and the presence of associated injuries p = 0.209 or their severity expressed in ISS p = 0.202. The highest ISS 29.5 points occurred in the group operated on by closed intramedullary nailing. Lack of complications in this group gives evidence of efficiency of this method of treatment.     

Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients

BACKGROUND: From 1989 to 1997, 1507 fractures of the shaft of the femur were treated with intramedullary nailing at The R Adams Cowley Shock Trauma Center. Fifty-nine (4 percent) of those fractures were treated with early external fixation followed by planned conversion to intramedullary nail fixation. This two-stage stabilization protocol was selected for patients who were critically ill and poor candidates for an immediate intramedullary procedure or who required expedient femoral fixation followed by repair of an ipsilateral vascular injury. The purpose of the current investigation was to determine whether this protocol is an appropriate alternative for the management of fractures of the femur in patients who are poor candidates for immediate intramedullary nailing. METHODS: Fifty-four multiply injured patients with a total of fifty-nine fractures of the shaft of the femur treated with external fixation followed by planned conversion to intramedullary nail fixation were evaluated in a retrospective review to gather demographic, injury, management, and fracture-healing data for analysis. RESULTS: The average Injury Severity Score for the fifty-four patients was 29 (range, 13 to 43); the average Glasgow Coma Scale score was 11 (range, 3 to 15). Most patients (forty-four) had additional orthopaedic injuries (average, three; range, zero to eight), and associated injuries such as severe brain injury, solid-organ rupture, chest trauma, and aortic tears were common. Forty fractures were closed, and nineteen fractures were open. According to the system of Gustilo and Anderson, three of the open fractures were type II, eight were type IIIA, and eight were type IIIC. Intramedullary nailing was delayed secondary to medical instability in forty-six patients and secondary to vascular injury in eight. All fractures of the shaft of the femur were stabilized with a unilateral external fixator within the first twenty-four hours after the injury; the average duration of the procedure was thirty minutes. The duration of external fixation averaged seven days (range, one to forty-nine days) before the fixation with the static interlocked intramedullary nail. Forty-nine of the nailing procedures were antegrade, and ten were retrograde. For fifty-five of the fifty-nine fractures, the external fixation was converted to intramedullary nail fixation in a one-stage procedure. The other four fractures were associated with draining pin sites, and skeletal traction to allow pin-site healing was used for an average of ten days (range, eight to fifteen days) after fixator removal and before intramedullary nailing. Follow-up averaged twelve months (range, six to eighty-seven months). Of the fifty-eight fractures available for follow-up until union, fifty-six (97 percent) healed within six months. There were three major complications: one patient died from a pulmonary embolism before union, one patient had a refractory infected nonunion, and one patient had a nonunion with nail failure, which was successfully treated with retrograde exchange nailing. The infection rate was 1.7 percent. Four other patients required a minor reoperation: two were managed with manipulation under anesthesia because of knee stiffness, and two underwent derotation and relocking of the nail because of rotational malalignment. The rate of unplanned reoperations was 11 percent. The average range of motion of the knee was 107 degrees (range, 60 to 140 degrees). CONCLUSIONS: We concluded that immediate external fixation followed by early closed intramedullary nailing is a safe treatment method for fractures of the shaft of the femur in selected multiply injured patients.     

弹性髓内钉与钢板内固定治疗儿童股骨干骨折疗效比较

目的比较弹性髓内钉与钢板内固定治疗儿童股骨干骨折的临床疗效。方法将64例儿童股骨干骨折患儿按治疗方法分为两组:A组(34例)采用闭合复位弹性髓内钉内固定,B组(30例)采用切开复位钢板内固定。术后定期随访,比较两组的手术时间及骨折愈合时间,依照Kolmert et al功能评定标准评价患者术后膝关节活动、疼痛、稳定性及肌力情况。结果患者均获得随访,时间10~24个月。A组的手术时间及骨折愈合时间明显短于B组(P0.05)。功能评价:A组优18例,良14例,可2例,优良率94.1%;B组优8例,良14例,可6例,差2例,优良率73.3%;A组疗效优于B组(P0.05)。结论与钢板内固定相比,闭合复位弹性髓内钉内固定治疗儿童股骨干骨折骨折愈合时间较短,功能恢复较好。     

双股骨干骨折治疗方式的选择

报告双股骨干骨折23例的治疗结果,年龄4.5～47岁,平均合并损伤3.1处。属股骨开放性骨折12侧,按Gustilo分类:Ⅰ型2侧,Ⅱ型5侧,Ⅲ型5侧。全组死亡2例,余21例行双侧牵引治疗4例,1侧牵引、1侧手术治疗2例,双侧手术治疗15例。平均随访3.8年,平均骨愈合时间3.6个月,手术者无1例发生深部感染,功能属正常或基本正常33侧(78.6％)。作者认为:双股骨干骨折的治疗,应根据合并伤的轻重、骨折类型、开放损伤程度及患者年龄来决定治疗方式,对成人应尽量采用手术治疗,而对儿童则首选仍为牵引。必要时可行1侧手术,1侧非手术或双侧手术以简化治疗,利于骨折愈合及其他伤情的恢复。     

两种手术方法治疗股骨干合并同侧股骨颈骨折的疗效比较

目的 比较股骨重建钉与逆行髓内钉加空心钉治疗股骨于合并同侧股骨颈骨折的疗效,探讨各自的手术适应证.方法 回顾性分析2001年1月至2010年5月收治的21例股骨干合并同侧股骨颈骨折患者资料,采用股骨重建钉固定10例(股骨重建钉组),逆行髓内钉加空心钉固定11例(逆行髓内钉加空心钉组).两组患者术前一般资料差异均无统计学意义(P＞0.05),具有可比性.术后1、3、6、9、12个月及以后每年随访1次,通过临床和影像学评估骨折愈合情况和并发症的发生情况.结果 21例患者术后获12 ～48个月(平均27.1个月)随访.两组患者在手术时间、术中出血量、术后引流量、住院时间、股骨干骨折愈合时间、股骨颈骨折愈合时间及Friedman-Wyman功能评定结果等方面差异均无统计学意义(P＞0.05).股骨重建钉组住院费用高于逆行髓内钉加空心钉组,差异有统计学意义(t=16.710,P=0.016).两组股骨干骨折愈合率(9/10 vs.10/11)、股骨颈骨折愈合率(9/10 vs.11/11)差异均无统计学意义(P＞0.05).股骨重建钉组4例发生并发症,逆行髓内钉组7例发生并发症.结论 股骨干合并同侧股骨颈骨折的治疗应采取个体化原则.股骨重建钉更适用于股骨颈基底部骨折合并狭部及狭部以近的股骨干骨折;对于头下型、难复位的股骨颈骨折合并同侧股骨干远端骨折或需要同时处理的膝关节内损伤、关节周围骨折的患者,逆行髓内钉加空心钉更为理想.     

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.     

Management of non-union of humeral fractures with the Stryker T2™ compression nail

Introduction  

Fractures of the humeral shaft are relatively common injuries and the majority achieve union uneventfully; however, non-union rates of up to 13% are reported when managed either conservatively or operatively. Despite the many surgical techniques described for the management of non-unions, including plate fixation, intramedullary nailing or external fixation, some cases remain resistant to treatment with ongoing problems achieving union.     

可膨胀式自锁髓内钉治疗股骨干骨折不愈合12例

目的探讨可膨胀式自锁髓内钉治疗股骨干骨折不愈合患者的临床疗效。方法2005年4月至2008年4月在我院采用可膨胀式自锁髓内钉治疗12例股骨干骨折不愈合患者,其中肥大性不愈合7例,萎缩性不愈合5例。术中取出原有的固定物,去除骨折端硬化骨,钻通髓腔,顺行插入可膨胀式自锁髓内钉,5例萎缩性不愈合患者均植入自体骺骨松质骨。结果经过14个月的随访,12例股骨干骨折不愈合患者中11例获得了愈合,治愈率达91．7％。平均愈合时间为22．1周,没有出现感染、内固定断裂、神经血管损伤、旋转畸形及明显的短缩畸形等并发症。结论可膨胀式自锁髓内钉治疗股骨干骨折不愈合治愈率高,并发症少,是值得推荐的一种治疗方法。     

Treatment of ipsilateral femoral neck and shaft fractures

Objective：To investigate the clinical characteristics, treatment options and causes of misdiagnosis of ipsilateral femoral neck and shaft fractures.
Methods： Among 20 patients with ipsilateral femoral neck and shaft fractures, 19 were treated operatively and 1 was treated conservatively. Sixteen cases of femoral shaft fractures were treated by open reduction and internal fixation with compressive plate, and 2 cases were treated with interlocking intramedullary nailing. Eighteen femoral neck fractures were treated with cannulated screws. Another patient was treated with proximal femoral nail to fix both the neck and shaft. Delayed diagnosis for femoral neck frac-tures occurred in 2 cases preoperatively. Results： A total of 19 patients were followed up. The follow up period ranged from 5 to 48 months with an average of 15 months. All the fractures were healed.
Conclusion： For case of femoral shaft fracture caused by high energy injury, an AP pelvic film should be routinely taken. Once the femoral neck fracture is recognized, operative reduction and fixation should be performed in time. Femoral neck and shaft fractures should be fixed separately.