Pediatric femoral fractures: a systematic review of 2422 cases

BACKGROUND: The incidence of femoral fractures in children comprise 20 per 100,000 yearly in the United States and Europe. The treatment of femoral shaft fractures in the pediatric population remains controversial. The child's age often directs the management. Nonoperative treatment options include functional treatment for the very young, Pavlic harness, skin or skeletal traction, and spica casting. Operative treatment options include closed reduction and external fixation, open reduction and internal plate fixation, closed reduction and minimally invasive plate osteosynthesis (MIPO), and closed reduction and intramedullary nailing with either flexible or rigid nails. The effect of operative versus nonoperative treatment has been the focus of several comparative studies. OBJECTIVE: To determine the effect of different treatment options on the rate of union, malunion, leg-length discrepancy (LLD), complications, and outcome after femoral shaft fractures in children.     

Closed treatment of displaced diaphyseal both-bone forearm fractures in older children and adolescents

The management of adolescent radius and ulna diaphyseal fractures is controversial. The purpose of this study was to address the residual deformity and functional outcome following closed treatment of these fractures. Twenty-five older children and adolescents (mean age 13.3 years, range 8.8-15.5) with displaced diaphyseal both-bone forearm fractures underwent closed treatment and were followed for a mean of 49.6 weeks. All fractures united. On the final AP radiograph, the mean angulation was 9 degrees (range 0-18 degrees) for the radius and 8 degrees (0-20 degrees) for the ulna. All patients achieved full elbow and wrist range of motion. Loss of forearm supination and pronation averaged 4 degrees (range 0 to 20 degrees) and 6.8 degrees (0 to 40 degrees), respectively. Closed reduction and casting of displaced both-bone diaphyseal forearm fractures, despite the residual angulation, results in satisfactory functional outcome and should remain a viable treatment option in the management of this injury.     

Compartment syndrome following intramedullary fixation of pediatric forearm fractures

This study was designed to evaluate the incidence of compartment syndrome (CS) resulting from the treatment of both-bone forearm fractures in children. A retrospective analysis of 285 consecutive children who presented with both-bone forearm fractures was performed. Of 235 closed injuries, 205 were treated with closed reduction and casting; none of these patients developed CS. Thirty of the closed injuries were treated with closed reduction and intramedullary fixation; three of these patients (10%) developed CS. Fifty patients sustained open fractures and were treated with debridement and open reduction with intramedullary pinning; CS developed in three of these patients (6%). The eighty patients treated with intramedullary fixation had an increased incidence of CS compared with the 205 patients treated with closed reduction and casting (P < 0.001). Within the group of patients who had surgery, patients with longer operative times and more use of intraoperative fluoroscopy were at higher risk of developing CS.     

Treatment of pediatric both-bone forearm fractures: a comparison of operative techniques

Both-bone forearm fractures of the radius and ulna are a common injury in children. Closed reduction and casting has historically been the primary means of treatment in over 90% of these fractures. Unstable and irreducible fractures, however, often pose a therapeutic challenge, with little data available to compare outcomes. The authors performed a retrospective review of 50 children with both-bones fractures treated with closed reduction and cast immobilization, open reduction and internal fixation (ORIF), or intramedullary (IM) nailing. Complications were tabulated and separated by treatment modality and subdivided into minor/major complications. Statistical regression was performed. There were 54 operations in 50 patients with both-bones fractures. All fractures healed within 8 to 10 weeks, except for two delayed unions and one nonunion. The complication rate was 5% for closed treatment, 33% for ORIF, and 42% for IM nailing. Complication rates were significantly different between the closed and operative groups. When comparing treatments in pediatric both-bones fractures, there are significantly more complications with operative techniques. Patients with ORIF had more major complications, often requiring a return to the operating room. IM nailing, when done correctly, is as acceptable and safe a form of treatment.     

The management of forearm fractures in children: a plea for conservatism

A retrospective review was undertaken to evaluate the efficacy of primary nonoperative treatment (closed reduction and long-arm casting) along with pins and plaster as a salvage technique for those reduction failures. A total of 730 closed fractures (1987-1993) was compiled, of which 300 required closed reductions and casting. Excluded from the study were teenagers whose growth plates were closed. Of the 300 fractures requiring closed reductions, 22 went on to require remanipulations, and 12 required the use of pins-and-plaster technique to obtain or maintain satisfactory reduction. Complications in the group treated in this manner included two superficial pin infections treated with antibiotics and two forearms with moderate loss of pronation/supination not requiring treatment. We believe that closed reduction of pediatric forearm fractures remains the accepted standard and the technique of pins and plaster should be considered a reliable alternative for the unstable injuries.     

Immobilisation of forearm fractures in children: extended versus flexed elbow

Redisplacement of unstable forearm fractures in plaster is common and may be the result of a number of factors. Little attention has been paid to the influence of immobilisation with the elbow extended versus flexed. We prospectively treated 111 consecutive children from two centres with closed forearm fractures by closed reduction and casting with the elbow either extended (60) in China or flexed (51) in Israel. We compared the outcome of the two groups. There was no statistically significant difference in the distribution of the age of the patients, the site of fracture or the amount of angulation and displacement between the groups. During the first two weeks after reduction, redisplacement occurred in no child immobilised with the elbow extended and nine of 51 children (17.6%) immobilised with the elbow flexed. Immobilisation of unstable forearm fractures with the elbow extended appears to be a safe and effective method of maintaining reduction.     

Pediatric forearm fractures: Indications, technique, and limits of conservative management

Summary Although several “minimal invasive” techniques for the operative management of pediatric forearm fractures have been developed recently, conservative treatment still remains the option with the lowest risk for small patients. We present the results of our clinical and radiological follow-up after an average of 52.4 months (4–112) in 102 pediatric patients. All fractures were treated conservatively. There were 68 fractures (66.7 %) of the distal third of the forearm, 30 fractures (29.4 %) of the midshaft area, and four fractures (3.9 %) in the proximal third of the shaft. Greenstick fractures were seen in 58 cases (56.8 %), complete fractures with displacement of both corticalices in 26 patients (25.5 %), and folding fractures in 18 cases (17.7 %). With the exception of one fracture with the necessity of remanipulation after redisplacement in the cast, all fractures healed uneventfully without any further intervention. Functional results were excellent with a free range of motion of the wrist and elbow and without any signs of muscular atrophy in 96 children (94.1 %) at the time of follow-up. Six patients, however, showed a significant loss of forearm rotation of an average of 25 ° (15 °–50 °). In four of these six patients, the fracture had been situated in the proximal and midshaft area. Thus, two out of four fractures of the proximal forearm (50.0 %) showed a poor functional outcome. On the basis of our data we recommend conservative management for (closed) pediatric fractures of the distal and midshaft area. Operative treatment is indicated in forearm fractures close to the elbow.      

Pediatric forearm fractures: Indications, technique, and limits of conservative management Indikationen, Technik und Grenzen der konservativen Behandlung

Although several “minimal invasive” techniques for the operative management of pediatric forearm fractures have been developed recently, conservative treatment still remains the option with the lowest risk for small patients. We present the results of our clinical and radiological follow-up after an average of 52.4 months (4–112) in 102 pediatric patients. All fractures were treated conservatively. There were 68 fractures (66.7 %) of the distal third of the forearm, 30 fractures (29.4 %) of the midshaft area, and four fractures (3.9 %) in the proximal third of the shaft. Greenstick fractures were seen in 58 cases (56.8 %), complete fractures with displacement of both corticalices in 26 patients (25.5 %), and folding fractures in 18 cases (17.7 %). With the exception of one fracture with the necessity of remanipulation after redisplacement in the cast, all fractures healed uneventfully without any further intervention. Functional results were excellent with a free range of motion of the wrist and elbow and without any signs of muscular atrophy in 96 children (94.1 %) at the time of follow-up. Six patients, however, showed a significant loss of forearm rotation of an average of 25 ° (15 °–50 °). In four of these six patients, the fracture had been situated in the proximal and midshaft area. Thus, two out of four fractures of the proximal forearm (50.0 %) showed a poor functional outcome. On the basis of our data we recommend conservative management for (closed) pediatric fractures of the distal and midshaft area. Operative treatment is indicated in forearm fractures close to the elbow.     

Outcomes assessment of pediatric both-bone forearm fractures treated operatively

This study assessed the outcome of pediatric both-bone forearm fractures treated with operative intervention. A retrospective review was conducted of 31 patients treated over a 40-month period. Fifteen patients were treated with flexible intramedullary nailing and 16 treated with open reduction and internal fixation. Average patient age was 11 years (range: 3.8-17.9 years). Operative indications included 2 open fractures and 29 fractures with unacceptable reductions. The intramedullary nailing group had 14 excellent results and 1 good result. The open reduction internal fixation group had 15 excellent results and 1 good result. Overall, 29 (93.5%) of 31 patients had excellent results. Two minor complications occurred in the intramedullary nailing group and none in the open reduction internal fixation group. Although operative intervention in pediatric both-bone forearm fractures is rarely indicated, when necessary, good results can be expected.     

Position of immobilization for pediatric forearm fractures

The purpose of this study was to evaluate the effect of forearm position on residual fracture angulation for pediatric distal-third forearm fractures at the time of union. One hundred nine pediatric distal-third forearm fractures undergoing closed reduction and casting were prospectively randomized to be immobilized in pronated, supinated, or neutral position. Initial angulation and displacements were radiographically compared with healed fracture angulation at a minimum of 6 weeks. With 99 complete patient files, 38 fractures were casted in neutral, 26 in pronated, and 35 in supinated positions. Average initial angulation was 20 degrees; postreduction angulation measured 3 degrees. Final angulation at union averaged 7 degrees for all fractures. Forearm position failed to show a significant effect on fracture angulation at union. Residual fracture angulation at the time of union for pediatric distal-third forearm fractures was not significantly affected by forearm position (pronation, supination, neutral) during cast immobilization.     

Mid-third forearm fractures in children: an unorthodox treatment

Twenty children with fractures of both bones in the middle third of the forearm were immobilized in extension after closed reduction. Unlike distal-third fractures, these fractures are prone to develop rotary and angular deformities that may lead to permanent functional impairment and visible deformity. Mid-third forearm fractures with the radius fracture proximal to the ulnar fracture are even more troublesome. Nineteen patients had no clinical deformity at cast removal, and by 1 year, there was no difference in forearm rotation. Extension casting can be used initially for proximal fractures or to salvage forearms that lost reduction in flexed elbow casts. Extension cast application is easy while the reduction is maintained, whereas the problems are often encountered while applying a flexed elbow cast. This unorthodox treatment is safe and effective and may alleviate the need for surgical intervention.     

Closed reduction with percutaneous Kirschner wire drill-and-pry for pediatric supracondylar humeral fractures with bony callus formation and delayed presentation

BackgroundSupracondylar humeral fractures are the most common type of pediatric elbow fractures, and are primarily treated using closed reduction and percutaneous pinning. For patients who are treated ≥14 days after the injury, after callus formation has occurred, closed reduction is usually not possible. The purpose of this study is to report the clinical outcomes of closed reduction with percutaneous Kirschner wire (K-wire) drill-and-pry for the delayed treatment of pediatric supracondylar humeral fractures with bony callus formation.MethodsWe retrospectively reviewed the data of 16 patients who underwent percutaneous K-wire drill-and-pry between November 2019 and August 2021 for the treatment of supracondylar humeral fractures with bony callus formation ≥14 days after the injury. Clinical outcomes were assessed using the Flynn criteria. The postoperative Baumann angle and pin configuration were evaluated using x-ray examinations.ResultsAll patients were followed up for 8–28 months (average, 16.63 months). The fractures healed in 4–6 weeks (average, 4.38 weeks). The operative time ranged from 10 to 124 min (average, 35.12 min). No iatrogenic vascular or nerve injury occurred. No patient developed cubitus varus. According to the Flynn criteria, 12 patients had excellent outcomes, 2 patients had good outcomes, 1 patient had a fair outcome and 1 patient had a poor outcome.ConclusionClosed reduction with percutaneous K-wire drill-and-pry is a mini invasive technique for supracondylar humeral fractures with bony callus formation in children. Most patients had a good clinical and cosmetic outcomes without scarring.     

Open Versus Closed Operative Treatment for Tongue-Type Calcaneal Fractures: Case Series and Literature Review

Because consensus on the optimal surgical treatment of tongue-type calcaneal fractures is lacking, this study aimed to compare outcomes and postoperative complications of open and closed surgical treatment of these fractures. For this cases series, all patients 18 years or older who underwent operative fixation of tongue-type calcaneal fractures at 2 level I trauma centers between 2004 and 2015 were considered eligible for participation. Data on explanatory and outcome variables were collected from medical records based on available follow-up. Additionally, a systematic literature review on surgical treatment of these fractures was conducted. Fifty-six patients (58 tongue-type fractures) were included. Open reduction internal fixation was performed in 33 fractures, and closed reduction internal (percutaneous) fixation was performed in 25. More wound problems and deep infections were observed with open treatment compared with the closed approach: 10 (30%) versus 3 (12%) and 4 (12%) versus 0 (0%) procedures, respectively. In contrast, revision and hardware removal predominated in patients with closed treatments: 4 (16%) versus 1 (3%) and 9 (36%) versus 8 (24%) procedures, respectively. The systematic literature review yielded 10 articles reporting on surgical treatment for tongue-type fractures, all showing relatively good outcomes and low complication rates with no definite advantage for either technique. Both open and closed techniques are suggested as accurate surgical treatment options for tongue-type calcaneal fractures. Surgical treatment should be individualized, considering both fracture and patient characteristics and the treating surgeon's expertise. We recommend attempting closed reduction internal fixation if deemed feasible, with conversion to an open procedure if satisfactory reduction or fixation is unobtainable.     

Displaced intra-articular calcaneal fractures

BACKGROUND: Calcaneal fractures comprise 1 to 2 percent of all fractures. Approximately 75% of calcaneal fractures are intra-articular. The management of intra-articular calcaneal fractures remains controversial. Nonoperative treatment options include elevation, ice, early mobilization, and cyclic compression of the plantar arch. Operative treatment options include closed reduction and percutaneous pin fixation, open reduction and internal fixation, and arthrodesis. The effect of operative versus nonoperative treatment has been the focus of several comparative studies. OBJECTIVE: This study was designed to determine the effect of operative treatment compared with nonoperative treatment on the rate of union, complications, and functional outcome after intra-articular calcaneal fracture in adults.     

Open intramedullary Kirschner wire versus screw and plate fixation for unstable forearm fractures in children

PURPOSE. To compare the outcomes of intramedullary Kirschner wire versus screw and plate fixation for unstable forearm fractures in children aged older than 10 years. METHODS. Records of 32 children aged 10 to 15 (mean, 12) years with displaced fractures of the radius and ulna were retrospectively reviewed. 17 boys and 4 girls underwent intramedullary Kirschner wiring, whereas 10 boys and one girl underwent plating. All patients had been initially treated with closed reduction and casting. Indications for surgical intervention were fractures with angulation of >10 degrees and total displacement. Patients were followed up for a mean of 24 (range, 13-40) months. Angulation and range of movements of the elbow, wrist, and forearm, as well as clinical and cosmetic results were compared. RESULTS. Both treatments achieved excellent clinical outcomes, but intramedullary Kirschner wiring resulted in better cosmesis, shorter operating times, easier hardware removal, and lower implant costs. CONCLUSION. Intramedullary Kirschner wiring is a better option than plating for the treatment of unstable forearm fractures in older children.     

Monteggia fractures in pediatric and adult populations

A Monteggia fracture is a fracture of the proximal ulna coupled with a radial head dislocation. These fractures are an uncommon class of forearm fractures. Numerous classification systems have been developed to characterize these fractures, with the Bado classification being the most common. Elbow radiographs are the primary diagnostic modality, demonstrating dislocation when a line drawn extending through the radial head from the radial shaft does not penetrate the capitellum in all views. Notable differences exist in the prevalence, treatment, and outcomes of Monteggia fractures for pediatric and adult patient populations, with adolescents often achieving a better prognosis. Nonoperative management with closed reduction and cast immobilization often prevails in pediatric patients, dictated by the pattern of the ulnar fracture more so than the direction of the radial head dislocation. However, in adults, operative intervention is frequently indicated because angulation and shortening of the ulna often occur after closed reduction. Although the orthopedic community's understanding of these fractures has evolved, the fractures themselves remain a challenging clinical phenomenon. This article reviews the relevant anatomy and pathogenesis, classification, clinical presentation, diagnostic studies, management, outcomes, and complications of Monteggia fractures in children and adults.     

Pediatric elbow and forearm fractures requiring surgical treatment

In the modern pediatric orthopedic practice, operative management plays a vital and not infrequent role in the management of significant and difficult forearm and elbow fractures in the skeletally immature. Although the majority of forearm and many elbow fractures can be treated successfully by nonoperative measures, operative intervention is warranted in selected cases to optimize outcomes. Anatomic reconstruction of articular surfaces, along with obtaining and maintaining a stable, anatomic fracture reduction, are the goals of any operative treatment. Appropriate use of surgical techniques for pediatric forearm and elbow fractures, when indicated, is essential to optimize results and achieve the ultimate goal of a pain-free functional extremity for the child.     

Operative Management of a Pediatric Talar Body and Neck Fracture: A Case Report

Pediatric talus fractures are rare injuries that generally result from high-energy trauma. The relative elasticity of pediatric bone is thought to contribute to the lower rate of fracture in children. Although these injuries are rare, complications of talar body fractures, including avascular necrosis, collapse of the talar dome, and tibiotalar arthrosis, are well described. In the pediatric patient, these complications can result in poor outcomes and a disabling position for the patient. There is a relative paucity of data given the low incidence of these injuries and lack of consensus on operative versus nonoperative management. The authors present the case of an 11-year-old female with a combined talar neck and body fracture. The patient underwent open reduction internal fixation of her fractures with combined cannulated screw and Kirshner wire fixation. She was followed to 7 years postoperatively with excellent functional outcome and no evidence of avascular necrosis or collapse of the talar body.     

Nonunion of forearm fracture: a rare instance in a toddler

When compared to adults, pediatric fractures unite readily and nonunion is quite rare. Nonunion is often associated with open fractures, operative interventions, infection, pediatric osteogenesis imperfecta and neurofibromatosis. There are only a few studies and reports mentioning nonunion following conservative management of closed pediatric fractures. We report here a case of an eighteen-month-old child who developed nonunion following treatment of fracture of both forearm bones with cast and was successfully treated with plating. To the best of our knowledge, this is the youngest reported case of nonunion following conservative management of closed diaphyseal pediatric fracture.     

Redisplacement after closed reduction of forearm fractures in children

Reangulation and displacement after closed reduction of pediatric forearm fractures were reviewed in 90 patients treated with 1978-1984. All fractures were remanipulated and followed to union. No complications occurred and all had a functionally satisfactory result. Both intrinsic and extrinsic factors were identified as contributing to the complication of reangulation/displacement. Nonepiphyseal fractures were safely remanipulated up to 24 days postfracture, with the majority at 1-2 weeks. We conclude that 7% of pediatric forearm fractures treated by closed reduction are subject to reangulation and/or displacement following routine acceptable primary treatment, and that remanipulation provides a safe, effective means to obtain and maintain reduction.