Comparison of titanium elastic nails with traction and a spica cast to treat femoral fractures in children

BACKGROUND: Titanium elastic nails are commonly used to stabilize femoral fractures in school-aged children, but there have been few studies assessing the risks and benefits of this procedure compared with those of traditional traction and application of a spica cast. This prospective cohort study was designed to evaluate these two methods of treatment, with a specific focus on the first year after injury, the period when the treatment method should have the greatest impact. METHODS: Eighty-three consecutive children, six to sixteen years of age, were studied prospectively. Factors that were analyzed included clinical and radiographic data, complications, hospital charges, and outcome data. Outcome and recovery were assessed both with the American Academy of Orthopaedic Surgeons Pediatric Outcomes Data Collections Instrument, version 2.0, and according to a series of important recovery milestones including the time to walking with aids, time to independent walking, time absent from school, and time until full activity was allowed. RESULTS: Thirty-five children (thirty-five fractures), with a mean age of 8.7 years, were treated with traction and application of a spica cast, and forty-eight children (forty-nine fractures), with a mean age of 10.2 years, were treated with titanium elastic nails. All fractures healed, and no child sustained a complication that was expected to cause permanent disability. At one year after the fracture, eighty of the children had acceptable alignment and no inequality between the lengths of the lower extremities. The remaining three children, who had an unsatisfactory result, had been treated with traction and a spica cast. Twelve patients (34%) treated with traction and a cast had a complication compared with ten patients (21%) treated with titanium elastic nails. Compared with the children treated with traction and a cast, those treated with titanium elastic nails had shorter hospitalization, walked with support sooner, walked independently sooner, and returned to school earlier. These differences were significant (p < 0.0001). We could detect no difference in total hospital charges between the two groups. CONCLUSIONS: The results of this prospective study support the recent empiric observations and published results of retrospective series indicating that a child in whom a femoral fracture is treated with titanium elastic nails achieves recovery milestones significantly faster than a child treated with traction and a spica cast. Hospital charges for the two treatment methods are similar. The complication rate associated with nailing compares favorably with that associated with traction and application of a spica cast.     

Femoral shaft fractures in children—a comparison of treatment

Between April 1986 and March 1997, 83 femoral-shaft fractures in children 4-8 years old were treated at Christian Medical College and Hospital, Ludhiana, India. Among 35 patients with a minimum of 12 months follow-up, 14 were treated with Hamilton-Russell (HR) skin traction and 14 with proximal tibial skeletal traction. The group treated with HR traction had a shorter duration of (a) hospital stay (average 16.8 days versus 29.7 days for skeletal traction, p=0.02), (b) time to fracture consolidation (average 8.8 weeks versus 10.8 weeks for skeletal traction, p=0.04), and (c) return to normal activities (average 12.2 weeks versus 17.2 weeks for skeletal traction, p=0.03). At final follow-up (minimum 1 year), there were no significant differences in functional outcomes. Conservative management is still a gold standard for treatment of closed femoral shaft fractures in children 4-8 years of age. There appears to be no advantage to skeletal traction over skin traction in this age group.     

The effect of prereduction traction on the results of closed reduction of developmental dislocation of the hip

A group of 86 developmentally dislocated hips in children aged 6-48 months was treated by closed reduction before 1957 without preliminary traction, and another group of 176 hips was treated after 1957 with prereduction traction. The results in these two groups were compared to clarify the effect of prereduction traction. During the treatment of these cases, subcutaneous adductor tenotomy was performed when obviously indicated. Otherwise preliminary traction was the only variable between the two groups. To rule out tenotomy as a factor influencing the result, the hips of children aged 6-36 months who had prereduction traction as the single variable were taken out of the group and the results analyzed. It is concluded that prereduction traction decreases the incidence of avascular necrosis of the femoral head when developmentally dislocated hips of children aged 6-36 months are treated with closed reduction with traction as the single variable.     

Traction and spica casting for closed femoral shaft fractures in children

PURPOSE: To evaluate the treatment outcome of skin traction followed by spica casting for closed femoral shaft fractures in children. METHODS: Between September 1997 and December 2001 inclusive, outcomes of 63 children aged one month to 15 (mean, 5.3) years with closed femoral shaft fractures managed with skin traction and spica casting were reviewed. Depending on age, patients were kept in traction from 2 to 15 (median, 9) days, then in spica casts for 2 to 8 (median, 5) weeks. RESULTS: Bony union took 3 to 12 (median, 6) weeks. There were no malunion, nonunion, or rotational deformities. Nor were there any significant limb length discrepancies, pressure sores, or nerve palsies. On no occasion was a spica cast removed and reapplied for loss of fracture reduction. At final follow-up, limb length discrepancy was noted in 14 (22%) of the patients, but none had a discrepancy of greater than 1.5 cm or a short-legged gait. CONCLUSION: Skin traction followed by spica casting for closed femoral shaft fractures in children is safe, cost-effective and associated with a low complication rate. It is effective in children below 5 years of age and no less effective in older children, except in instances of open fracture, multiple fractures, or older children with large statures, which conditions render them intolerant to spica casts.     

Efficacy of perioperative halo-gravity traction in the treatment of severe scoliosis in children.

SUMMARY: Perioperative halo traction was used in the treatment of severe scoliosis in 19 children. Diagnoses included neuromuscular, idiopathic, and congenital scoliosis. Traction was transferable between the bed and a walker or wheelchair. Thirteen patients had prior spinal surgery, and most required osteotomy. Traction was used for 6 to 21 weeks. All patients underwent spinal fusion surgery after traction, with instrumentation used in 15 patients. Improvement was achieved in all patients. The Cobb angle improved 35% from an average 84 degrees before traction (range 63 degrees -100 degrees ) to 55 degrees preceding fusion. Trunk decompensation improved in all patients. Trunk height increased 5.3 cm in traction. Response to traction did not correlate with diagnosis, patient age, or prior surgery. There were no neurologic complications. Perioperative halo-gravity traction improves trunk balance and frontal and sagittal alignment in children with severe spinal deformity. Surgical fusion was enhanced by the improved alignment, and neurologic injury was avoided.     

One-stage combined surgery with or without preoperative traction for developmental dislocation of the hip in older children

PURPOSE. To compare one-stage combined surgery with and without preoperative traction, in older children with developmental dislocation of the hip (DDH). METHODS. Records of 9 children who underwent combined surgery for DDH with preoperative traction in 12 hips (group 1) and 12 undergoing the same procedure without preoperative traction in 16 hips (group 2) were retrospectively reviewed. The surgery consisted of open reduction, Salter's innominate osteotomy and femoral shortening with derotation varus osteotomy. The mean age of the patients at the time of operation was 5.8 years. The mean follow-up period was 5.9 years. RESULTS. At final follow-up, clinical outcome in group 1 was worse than that in group 2, though radiographic assessment demonstrated no significant difference between the groups. CONCLUSION. One-stage combined surgery without preoperative traction is effective in the treatment of DDH in older children, and has a lower complication rate, but radiographically the groups did not differ.     

Three-dimensional spiral CT scanning in children with acute torticollis

Three-dimensional spiral CT scanning is now becoming a common investigation in children who have a history of acute torticollis. In the last year, 21 consecutive children who came to our unit with a history of acute torticollis were assessed using standard plain radiographs and a 3-dimensional spiral CT scan. Ten patients had a history of recent trauma. Spiral CT scanning revealed that 13 children had atlanto-axial rotatory subluxation (AARS). Plain radiographs had only a sensitivity of 33% and specificity of 71% in detecting AARS. Sixteen children were treated using a Halter traction. Four failed to resolve clinically and were put on a halo traction after 3-dimensional CT scanning again confirmed residual AARS. Two children remained symptomatic after halo traction, with persisting rotatory and anterior subluxation on repeat spiral CT. They both underwent a posterior in-situ fusion, with no attempt at open reduction. Plain radiography is limited in investigating acute torticollis in children. Spiral 3-dimensional CT reconstruction has an important role to play in both the investigation and management of children who present with acute torticollis.     

Immediate double hip spica immobilization as the treatment for femoral shaft fractures in children

Fractures of the femur in children are usually the result of high-velocity injury. Older methods of treatment, i.e., prolonged traction, offer no advantage over early spica immobilization and markedly increase the hospitalization time and expense. It is recommended that traction be abandoned except in unusual circumstances.     

The role of pelvic traction in the management of primary monosymptomatic nocturnal enuresis

OBJECTIVE: To determine whether pelvic traction is beneficial in children with primary nocturnal enuresis. PATIENTS AND METHODS: There can be disproportionate growth between the spinal column and neural tube in prepubertal children. The normal elongation of the vertebral column in children during sleep could stretch the filum terminale and nerve roots, representing a minor degree of tethering that affects neural function and contributes to nocturnal enuresis. Pelvic traction induces a similar or more intense stretch while a patient is fully awake (and able to control their bladder). Releasing the potential tethering in this way, combined with conditioning therapy, could be beneficial. Fifty patients (aged 7-17 years) with monosymptomatic primary nocturnal enuresis were evaluated in a prospective study. All had 10 sessions of pelvic traction applied over 4 weeks and were followed up for 3 months afterward; no other medications were given. RESULTS: All patients had fewer wet nights, with variable degrees of success (20-80%) during and 3 months after traction. CONCLUSION: Pelvic traction is a safe, simple, economic and effective treatment for primary monosymptomatic nocturnal enuresis.     

Supracondylar fractures of the humerus in children. Treatment by straight lateral traction

Ninety-eight children with severely displaced supracondylar fractures of the humerus were treated by straight lateral traction. After a mean follow-up period of 3.5 years there were 90 satisfactory and only eight unsatisfactory results. Cubitus varus was present in only four children, which compares favourably with the results of operative treatment. The indications for straight lateral traction, and the advantages of this method, are discussed.     

Konservative Behandlung der isolierten Oberschenkelfraktur im Kindesalter

The principles of treatment for fractures of the femoral shaft in children include conservative and operative management. Traditionally, these fractures have been treated conservatively with skeletal traction. More frequent consideration is being given to the psychological and economical outcome. At what age of the patient surgery can be performed is still open to debate. From 1988 to 1999, 52 children with closed femoral shaft fractures were treated conservatively in the Klinik für Unfallchirurgie, Plastische und Wiederherstellungschirurgie der Universität Göttingen (until 1994 Klinik für Allgemeinchirurgie). Overhead traction was applied in 27 children with a mean age of 19.9 months (group I), and a 90–90 skeletal traction was performed in 25 children with a mean age of 47 months (group II). This treatment was followed by spica casting on an outpatient basis. At a mean follow-up of 6 11/12 years (2 4/12–12 5/12) in 33 children all fractures were healed and no malalignment with clinical relevance could be observed. In four patients the limb overgrowth was 15–20 mm. The assessment of psychological and somatic aspects revealed disturbances in the family environment. The average length of hospitalization was much shorter in group I (mean: 17.4 days) than in group II (mean: 23.7 days). Our study confirms the good long-term results after conservative treatment of femoral shaft fractures in children up to 6 years. Social and psychological problems due to the prolonged period of hospitalization as well as the high costs of skeletal traction favor surgical treatment for children older than 3–4 years.     

The comparison of the results of treatment of displaced supracondylar humeral fractures by skeletal traction and percutaneous K-wire fixation in children]

The aim of the study was to compare of the results of treatment of displaced supracondylar humeral fractures by skeletal traction and percutaneous K-wire fixation in children. We assessed retrospectively the type and result of treatment of 23 children. We obtained very good results in all cases treated by closed reposition secured by percutaneous K-wire fixation. In the group treated by skeletal traction, in 5 cases reposition was inadequate with subsequent limitation of range of motion in the elbow joint. According to our results closed reposition and percutaneous fixation should be the method of choice in displaced supracondylar humeral fractures in children.     

儿童肱骨髁上骨折手法复位失败后骨牵引与手术治疗比较

目的 评价儿童肱骨髁上骨折手法复位失败后骨牵引与手术治疗效果。方法 40例肱骨髁上骨折患者分成两组,分别采用骨牵引及手术两种治疗方法。结果 骨牵引与手术两组治疗结果优良率分别为15／20、16／20,差异无显著性（P〉0．05）。结论 虽两组疗效差异无显著性,但骨牵引治疗有较多优越性,以骨牵引治疗为佳。     

Treatment of femoral shaft fractures in children by early spica casting

Eighty-five children with femoral shaft fractures were studied prospectively to determine the benefits of early application of a single-hip spica cast. They were compared with 85 children with similar fractures treated by skin traction for 4 weeks followed by a spica cast for 2 weeks. The study revealed that femoral shaft fractures in children can be treated in a single-hip spica cast with results comparable to those achieved by traction. The additional advantages were substantial savings in cost, early reunion of child with parents and increased availability of beds.     

Spätergebnisse nach der Behandlung von kindlichen Oberschenkelschaftbrüchen

Out of a series of 117 children (age 0–14 years) with femoral shaft fractures 65 patients were followed-up at an average of 10 years after injury. Examination was performed with special regard to torsion deformities and complaints or roentgenologically detectable prearthrotic changes. Individual differences in anteversion angle were found frequently, but there was no correlation to any complaints. The average anteversion angle of all injured and of all non injured femurs showed no difference and all values were found to be in physiological range. Our long-term results indicate, that unilateral wire traction is a sufficient way to obtain excellent results in the treatment of femoral shaft fractures in children.     

A cost analysis of three methods of treating femoral shaft fractures in children: a comparison of traction in hospital, traction in hospital/home and external fixation

INTRODUCTION: There is no consensus as to which is best treatment of femoral fractures in children. PATIENTS AND METHODS: We performed a cost analysis comparing three treatments of femoral shaft fractures in children aged 3-15 years at 3 hospitals during the same period (1993-2000). The analysis included total medical costs and costs for the care provider and were calculated from the time of injury up to 1 year. RESULTS: At hospital 1, treatment consisted of external fixation and early mobilization. At hospital 2, the treatment was skin or skeletal traction in hospital for 1-2 weeks, followed by home traction. At hospital 3, treatment was skin or skeletal traction in hospital until the fracture healed. RESULTS: The average total costs per patient were EUR 10,000 at hospital 1, EUR 23,000 at hospital 2, and EUR 38,000 at hospital 3. INTERPRETATION: The main factor for determining the cost of treatment was the number of days in hospital, which was lower in children treated with external fixation.     

生理盐水在儿童骨牵引针道护理中的应用研究

目的探讨生理盐水在儿童骨牵引针道护理应用的可行性。方法将2017年1月至2018年12月华中科技大学同济医学院附属武汉儿童医院小儿骨科收治的208例骨牵引患儿,根据入院时间段分为对照组(113例)和观察组(95例)。对照组使用75%乙醇对骨牵引针道进行常规护理(2次/d),观察组按需使用生理盐水对骨牵引针道进行护理。采用中文版儿童疼痛行为量表(FLACC)评估患儿针道护理时的疼痛情况,Checketts Otterburns感染分级系统评估患儿针道感染情况。结果针道护理时,观察组的FLACC评分为(1.58±0.71)分,优于对照组的(2.06±0.86)分,差异有统计学意义(t=4.280,P<0.001)。观察组发生针道Ⅰ度感染2例,感染发生率为2.11%(2/95);对照组发生针道Ⅰ度感染4例,Ⅲ度感染1例,感染发生率为4.42%(5/113);两组针道感染发生率比较,差异无统计学意义(Z=-1.15,P=0.248)。结论儿童骨牵引针道采用生理盐水按需护理,可预防针道感染发生,减轻针道护理时的疼痛刺激,提高患儿舒适度。     

Supracondylar fractures of the humerus in children.

We undertook a retrospective study of 39 children with displaced supracondylar fractures treated by delayed closed reduction with fluoroscopic guidance. After 3-5 days of side-arm traction, swelling had usually diminished sufficiently to allow the elbow to be safely hyperflexed to stabilize the fracture after elective closed reduction. This method yielded 92% good or excellent results. There were no vascular problems or Volkmann's contractures.     

桥式钢丝夹板外固定与Bryant牵引治疗小儿股骨干骨折的病例对照研究

目的：回顾性研究桥式钢丝夹板外固定治疗小儿股骨干骨折的临床疗效,并与传统Bryant牵引的疗效进行比较。方法：2006年6月至2009年6月收治的小儿股骨干骨折38例,采用桥式钢丝夹板外固定及Bryant牵引两种方法治疗。桥式钢丝夹板组21例中男15例,女6例;年龄8个月～5.3岁,平均（2.3±0.6）岁;按骨折部位分类,股骨上1/3骨折5例,中1/3骨折9例,下1/3骨折7例。Bryant牵引组中男10例,女7例;年龄10个月～3.2岁,平均（2.2±0.4）岁;按骨折部位分类,股骨上1/3骨折4例,中1/3骨折10例,下1/3骨折3例。对两组临床功能、X线愈合时间、负重时间及并发症等进行比较。结果：桥式钢丝夹板组与Bryant牵引组骨折平均愈合时间分别为（6.0±0.3）、（6.2±0.4）周,负重时间分别为（6.1±1.0）、（6.4±1.2）周,两组比较差异无统计学意义。桥式钢丝夹板组软组织并发症3例,Bryant牵引组13例,两组比较差异有统计学意义。根据临床疗效标准,桥式钢丝夹板组优17例,良3例,可1例,Bryant牵引组优12例,良4例,可1例;两组疗效比较差异无统计学意义。结论：桥式钢丝夹板外固定及传统Bryant牵引治疗小儿股骨干骨折均能获得较为理想的疗效,与Bryant牵引相比,桥式钢丝夹板外固定具有操作简单、护理方便、疗效安全可靠等优点。     

Results of treatment of displaced long bones fractures in children--comparison of different methods]

Authors compared functional results of treatment of 48 patients; 25 children with displaced supracondylar humeral fractures, 16 treated with skeletal traction (group I, mean age 7.9 year), 9 treated with closed reduction and percutaneous K-wire fixation (group II mean age 7.7 year), and 23 patients with displaced femoral shaft fractures, 10 treated with traction (group III, mean age 7.5 year), 13 treated with closed reduction and elastic intramedullary nailing. Good results after supracondylar humeral fractures were obtained in 37.5% of patients treated with traction and in 66.7% treated with percutaneous K-wire fixation, and after femoral fractures in 70% treated with traction and 84.6% treated with intramedullary nailing. The use of instrumental methods of treatment allowed to reduce significantly the duration of hospitalization (respectively: 19.8 vs. 6.4, and 28.5 vs. 9.5 days). In authors' opinion, a closed reduction secured by percutaneous K-wire fixation as well as a closed reduction with elastic intramedullary nailing are the methods of choice in treatment of discussed fractures in children.