Femoral malrotation following intramedullary nailing in bilateral femoral shaft fractures

Introduction  

This study was designed to evaluate the incidence of femoral malrotation in bilateral femoral shaft fractures.     

Ipsilateral femoral neck and shaft fractures: a retrospective analysis of two treatment methods

Background  No consensus exists regarding the optimal treatment of ipsilateral femoral neck and shaft fractures. The three major issues related to these fractures are the optimal timing of surgery, which fracture to stabilize first, and the optimal implant to use. In an effort to find answers to these three key issues, we report our experience of managing 27 patients with ipsilateral femoral neck and shaft fractures by using two different treatment methods, i.e., reconstruction-type intramedullary nailing and various plate combinations. Materials and methods  We divided patients into two groups. Group I included 15 patients (13 males and 2 females) who were operated with cancellous lag screws or dynamic hip screws (DHS) for fractured neck and compression plate fixation for fractured shaft of the femur. Group II included 12 patients (11 males and 1 female) who were operated with reconstruction-type intramedullary nailing. Results  Mean age was 33.2 and 37.9 years in group I and II, respectively. Mean delay in surgery was 5.9 and 5.4 days in group I and II, respectively. Average union time for femoral neck fracture in groups I and II were 15.2 and 17.1 weeks, respectively; and for shaft fracture these times were 20.3 and 22.8 weeks, respectively. There were 13 (86.6%) good, 1 (6.7%) fair and 1 (6.7%) poor functional results in group I. There were 10 (83.3%) good, 1 (8.3%) fair and 1 (8.3%) poor functional results in group II. Conclusions  Both of the treatment methods used in the present study achieved satisfactory functional outcome in these complex fractures. Fixation with plate for shaft and screws or DHS for hip is easy from a technical point of view. Choice of the treatment method should be dictated primarily by the type of femoral neck fracture and the surgeon’s familiarity with the treatment method chosen. The femoral neck fracture should preferably be stabilized first, and a delay of 5–6 days does not affect the ultimate functional outcome.     

Femoral shaft fractures in children

We report our experience with elastic stable intramedullary titanium nailing (ESIN) of femoral shaft fractures in children. From 1998 to 2001, we treated 31 children (20 boys), median age 6 (4-11) years, with ESIN for 29 closed and 2 grade I open femoral shaft fractures. We reviewed 30 children clinically after median 1.5 (1-3) years. Their median hospital stay was 6 (2-20) days. All fractures were radiographically united at a median of 7 (5-9) weeks. The nails were removed in 29 children after a median of 22 (6-38) weeks postoperatively. At follow-up, we found a leg-length discrepancy up to 1 cm in 6 children and 10 degrees of internal rotational deformity in 1 child. No angular deformity had occurred. Elastic stable intramedullary nailing seems to be a safe method for the treatment of femoral shaft fractures in children between 4 and 11 years of age.     

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 shaft fractures in brain-injured children.

Thirty-nine head injured, initially comatose children with 44 femoral shaft fractures were treated by various methods. Thirty-two eventually ambulated. Tibial skeletal traction and skin traction were ineffective methods of management. Internal fixation or distal femoral traction are advised.     

Repeat LISS treatment for femoral shaft fractures due to hardware failure: a retrospective analysis of eleven cases

Objective

To evaluate the effectiveness of a replating technique having a less-invasive stabilization system (LISS) for femoral shaft fractures due to LISS failure in adults.

Patients and methods

There were 11 patients with hardware failure of LISS for femoral shaft fractures, on an average of 50 days after the primary operation. The failed implants were removed, and the fractures were replated with a LISS following the rationale of biological osteosynthesis. Radiological fracture union and incidence of postoperative complications were employed to evaluate the effectiveness of this replating technique for femoral shaft fractures.

Results

Operative duration including removing failed hardware and replating fractures averaged 81.5 min, with an average blood loss of 330 ml. Patients had an average follow-up of 25.7 months. Radiological evaluation indicated that fracture union occurred in an average of 4.4 months in all patients. The length and alignment of the affected limb were satisfactory, and hardware failure did not recur.

Conclusion

The replating technique with LISS for femoral shaft fractures due to hardware failure of LISS can obtain satisfactory results when the appropriate rationale of biological osteosynthesis and functional exercise is followed.     

Operative treatment of femoral shaft fractures in children and adolescents

Although femoral shaft fractures constitute fewer than 2% of all fractures in children and adolescents, their treatment has produced many pieces of literature and years of controversy. Prevailing opinion has favored nonoperative and operative treatment, and a variety of techniques have been advocated to avoid complications such as nonunion, limb-length discrepancy, malalignment, osteonecrosis, and growth disturbance. Currently, operative methods of treatment generally are favored to allow early ambulation and shorter hospital stays and to avoid detrimental psychological and social effects often associated with prolonged nonoperative treatment, and to avoid complications. Options for operative fixation include external fixators, flexible and locked intramedullary nails, and compression and bridge plating. Although all of these can obtain good results in particular situations, there is no clear consensus of the indications for each. My choice for fixation of each fracture is based on consideration of a number of factors, including the age and size of the child, associated injuries, the location and pattern of the fracture, and the social situation of the child. In general, I prefer flexible nailing for younger children (6-10 years old) and locked nailing for adolescents at or near skeletal maturity. Bridge plating may be chosen for segmental, grossly comminuted fractures, whereas external fixation usually is reserved for severely comminuted or severe open fractures for which internal fixation is not appropriate.     

Diagnosis and treatment of common fractures in children: femoral shaft fractures and supracondylar humeral fractures

Femoral shaft fractures and supracondylar elbow fractures are two of the most common major pediatric injuries managed by the general orthopedic surgeon. Therapeutic choices frequently are influenced by many factors, including associated injuries, fracture type, and the child's age, social situation, and economic issues. Nonsurgical management of femoral shaft fractures has been a preferred and cost-effective treatment for most age groups, but recently the use of surgical techniques has gained popularity with the overall goal of rapid mobilization of the child. Supracondylar elbow fractures are diagnostically challenging and can result in severe acute and long-term complications. An understanding of fracture presentation, anatomic detail, and surgical applications will optimize the chances for successful outcomes.     

Remodelling and overgrowth after conservative treatment for femoral and tibial shaft fractures in children

One thousand nine hundred and eighty-four children who had received conservative treatment for shaft (diaphyseal and metadiaphyseal) fractures of lower limbs (1162 femoral, 822 tibial fractures) at an average age of 8.5 years (range 0–14 years) were reviewed by clinical and radiographic investigations at an average follow-up of 6.6 years (1–15 years). Particularly, two main features were evaluated: remodelling of (angular and rotational) deformities and post-traumatic overgrowth. Mechanisms underlying these processes are discussed, based on a review of the literature, and parameters conditioning their evolution are analysed. Finally, criteria for an acceptable reduction (and limits for residual deformities that may be tolerated) at the time of conservative treatment are proposed.     

弹性髓内钉治疗儿童股骨干骨折

目的探讨弹性髓内钉治疗儿童股骨干骨折的方法和疗效。方法采用弹性髓内钉内固定治疗儿童股骨干骨折32例。结果 32例均获随访,时间5～12个月,骨折全部愈合。按Flynn评分标准:优26例,良6例。无骨不愈合、畸形愈合和骨骺损伤等。结论弹性髓内钉内固定具有微创、不累及骨骺、并发症少等特点,是治疗儿童股骨干骨折的有效方法。     

Remodelling of angular deformity after femoral shaft fractures in children.

We reviewed 28 children with unilateral middle-third fractures of the femoral shaft who had an angular deformity after union of 10 degrees to 26 degrees. At an average follow-up of 45 months (20 to 66), we measured remodelling of the proximal physis, the distal physis and the femoral shaft. The average correction was 85% of the initial deformity. We found that 74% of correction occurred at the physes and only 26% at the fracture site. Neither the direction nor the magnitude of the angulation much influenced the degree of remodelling. Younger children remodelled only a little better than older children. We conclude that in children under 13 years of age, malunion of as much as 25 degrees in any plane will remodel enough to give normal alignment of the joint surfaces.     

Growth of the tibia after isolated femoral shaft fractures in children

The aim of the present study is to investigate the growth of the tibia after femoral shaft fractures in children. We were able to follow up 44 patients (32 male and 12 female) after a mean of 8 years (range, 5 to 15 years). The age in the time of injury was 3 till 13 years (mean 7 years). The length of the femur, tibia and leg was measured on X-rays of the entire leg, and the measurements were compared with the contralateral side. A statistically significant number of tibial elongations were observed in fractures that had healed in considerable malalignment (at least 1 cm shortening, dislocation of at least a half of the breadth of the femoral shaft, angular deformity of more than 10 °) (p = 0.003) and in fractures that were subjected to manipulation (secondary reduction, change of treatment or traction weight) during the healing process (p = 0.007). Furthermore, all 7 patients who had infection requiring treatment at the tibial plateau extension had more pronounced tibial growth. No significant difference was found between tibial growth and the age of the child at the time of injury, the type of fracture, the location of fracture and the mode of treatment. The following factors were evaluated as being clinically relevant: primary, largely anatomic reduction, avoidance of secondary manipulation and prevention of infection at the tibial plateau extension.     

Growth of the tibia after isolated femoral shaft fractures in children

The aim of the present study is to investigate the growth of the tibia after femoral shaft fractures in children. We were able to follow up 44 patients (32 male and 12 female) after a mean of 8 years (range, 5 to 15 years). The age in the time of injury was 3 till 13 years (mean 7 years). The length of the femur, tibia and leg was measured on X-rays of the entire leg, and the measurements were compared with the contralateral side. A statistically significant number of tibial elongations were observed in fractures that had healed in considerable malalignment (at least 1 cm shortening, dislocation of at least a half of the breadth of the femoral shaft, angular deformity of more than 10 degrees) (p = 0.003) and in fractures that were subjected to manipulation (secondary reduction, change of treatment or traction weight) during the healing process (p = 0.007). Furthermore, all 7 patients who had infection requiring treatment at the tibial plateau extension had more pronounced tibial growth. No significant difference was found between tibial growth and the age of the child at the time of injury, the type of fracture, the location of fracture and the mode of treatment. The following factors were evaluated as being clinically relevant: primary, largely anatomic reduction, avoidance of secondary manipulation and prevention of infection at the tibial plateau extension.     

Femoral nerve block: a simple and safe method of instant analgesia for femoral shaft fractures in children.

A simple safe technique of providing rapid, effective analgesia in children with femoral shaft fractures is described. It is particularly useful in patients who have associated head or abdominal injuries in the presence of which opiates should be withheld. The technique is recommended to all practitioners involved in the early care of femoral shaft fractures.     

Osteomyelitis following surgical treatment of femoral shaft fractures. Results of a community study

A retrospective analysis was made of 3,280 diaphyseal femur fracture surgically treated in 73 medical centres of the GDR. The conclusion drawn from this quality check was that the high osteomyelitis rate of 5.6 per cent had been primarily attributable to shortcomings in osteosynthesis techniques but also to inadequate choice of methods. The following conclusions may be derived from the study reduction of bone infections: The osteomyelitis rate in the wake of Küntscher's nailing was as low as 2.2 per cent. This was the best result in the context of simple fractures with closed soft-part trauma. The advantages of covered intramedullary nailing were particularly felt in cases in which optimum protection against infection was impossible for the given surrounding conditions. Plate osteosynthesis has proved to be the most effective approach to open fractures, provided careful wound dressing, non-invasive surgical techniques, and generous indication in favour of autogenic spongiosa transplantation. Interlocked nailing is considered to be the optional technique of osteosynthesis to cope with comminuted fractures. External stabilisation is urgently indicated in cases of massive traumatisation of the femoral diaphysis in conjunction with severe open lesions of soft parts.     

Operative treatment of femoral shaft fractures in children: a nine-year experience in a Saudi Arabian population

This is a retrospective analysis of 56 children under the age of 16 years who had femoral shaft fractures and were treated at the Asir Central Hospital by open reduction and internal fixation. The age range was 5–16 years (average 10.8 years). Two patients had bilateral femoral shaft fractures. Female–male ratio was 1:5.2. The two legs were almost equally affected. The most common area of fracture location was the mid-diaphyseal region, 35 cases (60.3%) and the most common type of fracture seen was closed transverse, 22 cases (37.9%). The most common cause of injury was motor vehicle accident, 36 cases (64.3%) and the most common associated injury was head injury, 28 cases (48.3%). A plate was most commonly used for internal fixation, 44 cases (75.9%). The most common immediate post-operative complication was bleeding, 25 cases (43.1%) and the most common late complication was knee joint stiffness, three cases (5.2%). Hospital stay ranged between 7 and 48 days (average 25.9 days). The most common causes of prolonged hospital stay were the associated injuries with the fractured femur. Of the total 58 femoral shaft fractures, there was one case (1.7%) of non-union, and of the 56 patients in this series one (1.8%) died. It is concluded that open reduction and internal fixation of femoral shaft fractures is a good modality of treatment in children in our environment.