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.     

Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications

Titanium elastic nailing is used instead of traction and casting in many European centers, but limited availability has prevented widespread use in North America. Before a planned general release in America, titanium elastic nails (TENs) were trialed at several major pediatric trauma centers. This multicenter study is a critical analysis of early results and complications of the initial experience. Overall, TENs allowed rapid mobilization with few complications. The results were excellent or satisfactory in 57 of the 58 cases. No child lost rotational alignment in the postoperative period. Irritation of the soft tissue near the knee by the nail tip occurred in four patients, leading to a deeper infection in two cases. As indications, implantation technique, and aftercare are refined, TENs may prove to be the ideal implant to stabilize many pediatric femur fractures, avoiding the prolonged immobilization and complications of traction and spica casting.     

Flexibility in fixation: an update on femur fractures in children

Although non-operative strategies remain a viable option for the management of some children's femur fractures, surgical management has become more popular and predictable, with potential complications better recognized and thus more easily avoided. This paper addresses the operative management of children's femur fractures highlighting the multiple techniques available to treat the spectrum of pediatric femur fractures. We present the applications of Elastic Stable Intramedullary Nailing and Locked intramedullary nailing, sub-muscular or open plating, and external fixation, and discuss the relative advantages and shortcomings of each technique. Cases are presented for illustration.     

The definition and treatment of pediatric subtrochanteric femur fractures with titanium elastic nails

PURPOSE: Titanium elastic nailing (TEN) has become more common in the treatment of pediatric femur fractures in many European centers and in North America over the past several years. Prior studies have shown that the use of TEN for midshaft femur fractures results in excellent outcomes with an earlier return to activity, earlier mobilization, and a shortened hospital stay. However, subtrochanteric femur fractures continue to remain a difficult subset of fractures to care for, with loss of reduction and nonunion being significant complications. Studies have differed regarding the definition of pediatric subtrochanteric femur fractures. The purpose of this study is to establish a reproducible method of defining pediatric subtrochanteric fractures and then apply that definition in a retrospective review of 13 patients who sustained subtrochanteric femur fractures treated with TEN at North Carolina Baptist Hospital using a modified technique that allows for improved fracture stability. METHODS: Charts and radiographs were retrospectively reviewed for all pediatric patients sustaining subtrochanteric femur fractures treated with TEN from the period of 2000 to 2004 at Wake Forest University. The TEN outcome measures scale was applied to determine their results. RESULTS: TEN allowed rapid mobilization with excellent or satisfactory clinical and radiographic results in all patients. CONCLUSIONS: Results suggest that the use of TEN for subtrochanteric femur fractures is a safe and effective method of fixation that benefits patients through early mobilization, shorter hospital stays, and fewer complications. SIGNIFICANCE: By applying the definition of subtrochanteric femur fractures described by the authors, results of future studies can be objectively compared and classified. TEN is a safe and effective alternative for treating most pediatric subtrochanteric fractures by decreasing the morbidity that occurs with other treatment modalities.     

Role of Ilizarov external fixator in the management of proximal/distal metadiaphyseal pediatric femur fractures

Given the constraints of a short metaphyseal fragment and adjacent growth plates, there are limited options for operative fixation of metadiaphyseal fractures of the femur in children. This article outlines the surgical technique and reports early results of metadiaphyseal pediatric femur fractures treated with an Ilizarov external fixator by a single surgeon. Ten skeletally immature males with 5 proximal and 5 distal metadiaphyseal femur fractures underwent closed reduction and application of an Ilizarov external fixator. Time in the fixator averaged 138 (range, 104-180) days. At a mean follow-up of 26 months, there were no cases of loss of reduction, refracture, malalignment, leg length inequality, or loss of knee and hip mobility. Although superficial pin tract infections were common, no patient developed deep infection or required premature pin removal. One patient developed a transient foot drop after external fixation for a distal metadiaphyseal fracture, which recovered after revision of the pin construct. A low profile Ilizarov fixator can be effective in the management of certain metadiaphyseal pediatric femur fractures that may be difficult to manage by traditional methods.     

Volkmann contracture and compartment syndromes after femur fractures in children treated with 90/90 spica casts

Nine pediatric patients (mean age 3.5 yrs) with low energy femur fractures were treated with 90/90 spica casts and developed leg compartment syndromes, Volkmann contracture, and ankle skin loss. These cases are detailed and a proposed mechanism leading to this devastating complication is explained. The authors believe the technique of an initial below knee cast, and then using that cast for applying traction while immobilizing the child in the 90/90 spica is potentially dangerous. Alternative spica application methods are advocated.     

Clinical outcomes following invasive versus noninvasive preoperative stabilization of closed diaphyseal femur fractures

Background

The use of invasive traction (INV-T) to stabilize femur fractures prior to fixation (open reduction and internal fixation, ORIF) remains controversial. Some centers have utilized noninvasive traction (NINV-T) or splinting preoperatively. It is possible that INV-T decreases hemorrhage. However, the use of INV-T in pediatric patients and for femoral neck fractures in adults is associated with worsened outcomes. We hypothesized that there is no difference in the need for transfusion between those who receive INV-T and NINV-T.

Methods

A retrospective study was performed at two level I and one level II trauma center from January 2006 to December 2009. Patients ??18?years with a closed diaphyseal femur fracture who underwent ORIF within 48?h of arrival were included. Patients were grouped by method of preoperative fracture stabilization. Primary endpoint was need for transfusion. A power analysis found that 94 patients were needed to detect a 25?% difference with 80?% power.

Results

Fifty-six (22?%) received INV-T and 199 (78?%) received NINV-T stabilization. No significant differences were found between groups in terms of age, injury severity score, or ORIF method. There was no significant difference between the two groups in the hemoglobin value on arrival, preoperative hemoglobin value, or the difference between admission and preoperative hemoglobin values. We did not find a significant difference in the need for red blood cell transfusion between the two groups. There was no difference in length of stay or discharge destination.

Conclusion

INV-T is not associated with improved outcomes in adult patients with closed mid-shaft femoral fractures who are operated upon within 48?h of arrival.     

The conservative management of fractures of the shafts of the phalanges of the fingers by combined traction-splintage

Recent publications discussing fractures of the shafts of the phalanges of the fingers discount their management by traction because of possible complications and difficulties of application. A technique using splintage combined with isometric skin traction, used for many years in Southampton, has proved effective and free of complications. The results of the treatment of eighteen consecutive appropriate fractures using this technique are discussed.     

The conservative treatment of femur fractures by Perkins traction. Management in adverse situations

In adverse situations and in hospitals of less prosperous countries, the operative treatment of fractures may for many reasons not be possible and conservative procedures remain the treatment of choice. This applies to the rule that under difficult conditions fracture treatment should be as conservative as possible and as operative as necessary, if at all feasible.This report goes on 109 Patients with femur fractures consecutively treated by Perkins traction in East African hospitals between Nov. 1991 and Sept. 1999. Out of them, 44 patients had wide open fractures, 41 of them caused by explosives and bullets. The Perkins procedure is a traction without a fixating splint. As soon as possible, the patient is forced to sit up in his bed, the removable parts of the springs are dropped and the patient starts with exercises flexing and stretching the knee. With the right traction weight and the bodys counterweight the fragments of the fracture find an alignment, and a malrotation of the distal fragment is prevented. Exercises as early as possible stimulate a rapid callus formation and prevent muscle atrophy and stiffness of the joints.We have seen 2 posttraumatic deep infections, 5 refractures in patients whose traction was removed too early or who fell down whilst walking with crutches. All patients had a good callus formation and in all patients, except two, the traction could be removed after 6-12 weeks, in the most cases even after 6-9 weeks. To the patients with refractures, the traction was reapplied and callus consolidation then occurred without major problems. At the time of removal of the traction all patients showed a flexion of the knee of at least 80 degrees -90 degrees and all were able to nearly fully stretch the knee joint.Compared with other methods of conservative treatment of femur fractures, Perkins traction has some advantages: simple management, immediate start of exercises, simple exercises, early callus formation, no stiffness of the joints and only few x-ray controls. Malalignment, non union, excessive shortening and rotation of the distal fragment are uncommon.     

Titanium elastic nails for pediatric femur fractures: lessons from the learning curve

Traditionally, the treatment of choice in managing pediatric femur fractures has been traction and casting. Newer methods have focused on earlier mobility and shorter hospitalization. Use of retrograde titanium elastic nails (TENs) can quicken stabilization while allowing enough motion at the fracture site to generate excellent callus. Since TENs were first introduced in North America, our Level 1 Pediatric Trauma Center has prospectively followed all of its TEN patients. In this article, we present lessons from the learning curve of our first 50 cases--focusing on complications and their prevention. In the course of obtaining predominately excellent results, we have learned several important principles regarding TEN preoperative planning, operative technique, and aftercare. The most common problem encountered has been irritation at the nail insertion site (18% of cases). Very proximal fractures may be more challenging; unstable fractures and fractures in larger, older children are best managed with a short period of adjunctive immobilization.     

Retrograde locking nail osteosynthesis of distal femoral fractures with the distal femoral nail (DFN)

Non-operative treatment with immobilization or isometric traction has been abandoned as treatment for fractures of the distal femur at the end of the 1960ies. The technique of open reduction and internal fixation with a condylar plate as suggested by the AO has been the golden standard since the 1970ies. However, anatomic reconstruction of the condylar region with interfragmentary screw fixation and axial realignment of the femur shaft with a plate are challenging procedures especially in the presence of severely compromised soft tissues and put periosteal blood supply at risk. Soft tissue complications, axial malalignment and delayed fracture healing times led to the consideration of alternative techniques, such as intramedullary nailing which has been practiced with success since the 1940ies by Gerhard Küntscher and colleagues for femoral shaft fractures with minimal complication rates and improved results after closed reduction. The era of retrograde femoral nailing began with the systematic approach through the intercondylar notch by Green. This paper reviews the biomechanical properties, indication, technique as well as potential hazards and pitfalls of fracture management with the AO "distal femoral nail" (DFN). With appropriate application this technique is suitable for all fractures of the distal third of the femoral shaft including highly instable bicondylar fractures without damage to the soft tissues and the knee joint.     

An Observational Cohort Study of the Adoption of Elastic Stable Intramedullary Nailing for the Treatment of Pediatric Femur Fractures in Kumasi,Ghana

Background

In high- and middle-income countries, elastic stable intramedullary nailing (ESIN) is the commonest treatment of femur fractures in children 5–11 years of age. At Komfo Anokye Teaching hospital (KATH) in Kumasi, Ghana, prior to this study all pediatric femur fractures were treated with skin traction to union. This study was designed to report the early results and costs of the adoption of ESIN at KATH to provide data to other low- and middle-income sites considering adoption of this surgical technique.

Methods

An observational cohort study that included 84 pediatric patients ages 3–14 years presenting with closed femur fractures and treated with either skin traction or ESIN. Multivariate logistic regression was used to compare the rate of treatment success between treatment groups.

Results

Treatment success (coronal and sagittal angulation less than 10 ° and shortening less than 15 mm at osseous union) was achieved in 92 % of the ESIN group versus 67 % of the skin traction group (odds ratio for ESIN group 9.28 (1.6–54.7); p = 0.0138). Average length of stay was significantly lower in the ESIN group (p = 0.001), but charges to patients were higher in the ESIN group (p < 0.001) because of the high cost of implants.

Conclusions

The initial experience of operative treatment of femoral shaft fractures in children using ESIN was positive, with improved rates of treatment success and no surgical complications. Because of the high cost of implants, direct costs of treatment remained higher with ESIN despite reductions in length of hospital stay.     

Postoperative management: hand therapy program following intrafocal pinning for juxtaarticular phalanx fractures

Intrafocal pinning is a fracture management technique for reduction and stabilization of juxtaarticular phalanx fractures. This technique provides fracture stability with minimal soft tissue disruption from surgery and allows early range of motion (ROM) of the interphalangeal joints. The purpose of this article is to discuss postoperative rehabilitation specific to the management of this fracture and fixation technique that facilitates early ROM, edema control, pin care, custom splinting, and therapeutic exercise.     

Closed femoral fractures: why not simple traction?

A study was conducted to evaluate the result of treating closed fractures of the femoral shaft by simple traction in a busy General Hospital with a view to reducing some of the complications experienced in conventional traction splintage devices and to obtaining early discharge from hospital. Functional bracing was used when possible for fractures in the middle of the shaft.Over a two-year-period 45 patients were studied. The preliminary findings indicate that simple skeletal traction applied to fractures of the shaft of the femur gives satisfactory results, reduces the complications of conventional management in a Thomas's splint and shortens the time in hospital. Supplementary functional bracing applied between the fourth and seventh weeks allows this earlier discharge.     

Erectile dysfunction after perineal compression in young men undergoing internal fixation of femur fractures

Erectile dysfunction (ED) following treatment for lower limb fractures is not uncommon. The mechanism is thought to be a perineal neurovascular traction injury acquired during surgery. Four young men who sustained femur fracture underwent reduction and intramedullary nail fixation. Post-operatively each presented with varying degrees of ED. Phosphodiesterase inhibitors were used in each case and sexual function returned in all. It is essential that a sexual history be taken in all patients after internal fixation of femur fractures so that treatment can be initiated early on if required. This serious complication from traction may be avoidable with careful patient positioning during traction.     

The floating knee in the pediatric patient. Nonoperative versus operative stabilization

The results of nonoperative and operative or rigid stabilization of ipsilateral femur and tibia fractures in children and adolescents were evaluated. Twenty-nine consecutive patients with open physes (30 affected extremities) were reviewed. Their mean followup was 8.6 years (range, 1.1-18.6 years). The nonoperative group consisted of 16 patients and 16 extremities treated by skeletal traction of the femoral fracture, closed reduction and splinting or casting of the tibia fractures, and eventual immobilization in a hip spica cast. The operative group, was comprised of 13 patients and 14 extremities in which one or both fractures were treated by open reduction and internal fixation, intramedullary fixation, or external fixation. Despite higher modified injury severity scores and skeletal injury scores, the patients who were treated operatively had a significantly reduced hospital stay, 20.1 days versus 34.9 days, respectively; decreased time to unsupported weightbearing, 16.8 weeks compared with 22.3 weeks, respectively; and fewer complications. Operative stabilization of the femur had a significant effect on decreasing the length of hospital stay and the time to unassisted weightbearing. The patients also were analyzed according to their age at the time of injury: 9 years of age or younger and 10 years of age and older. The younger children who were treated nonoperatively had an increased rate of lower extremity length discrepancy, angular malunion, and need for a secondary surgical procedure as compared with younger children who were treated operatively with rigid fixation. Based on the results of the current study, operative stabilization of at least the femur fracture and, preferably, both fractures in the treatment of a child with a floating knee is recommended, even for younger children.     

Swing design dynamic traction splinting for the treatment of intra-articular fractures of the digits.

The concept of treating acute PIP fractures with traction splinting to allow early motion to mitigate against the known deleterious effects of prolonged immobilization of this problematic joint has been around for a long time and was made popular by Schenck. Our author in this PF piece has modified a splint design of Griet Van Veldhoven to further refine the dynamic traction approach.     

Treatment of complex proximal interphalangeal joint fractures using a new dynamic external fixator: 15 cases

The management of proximal interphalangeal joint fractures of the fingers is difficult. Dynamic traction splinting systems are cumbersome and the Suzuki fixator does not prevent secondary fracture displacement. Fifteen cases were treated with a new dynamic external fixator with distraction, the Ligamentotaxor^®. In two cases, additional fixation was required with a screw. After 10 months, grip strength scored 85.7% compared with the contralateral hand, flexion achieved 76.3° and the extension deficit was 19.6°. The visual analogical scale pain level (VAS) was 1.9 and the Quick DASH score totalled 16.9. Revision treatment was needed for sepsis for one patient. A case of secondary fracture displacement was corrected in the outpatient clinic. Consolidation was achieved in all cases. In conclusion, despite imperfect outcomes for these complex fractures, we believe that the Ligamentotaxor^® technique is useful.     

Intramedullary locked nailing for distal femoral fractures

Surgical Principles Distal femoral fractures, supracondylar and condylar fractures which can be successfully reduced by closed methods are treated with a modified method of intramedullary locked nails. Closed reduction is obtained by adducting the distal fragment and by adjusting the degree of knee flexion and extension. Condylar fractures, if present, are reduced closed and fixed with percutaneous lag screws. After preparing the medullary cavity, the distal 15 mm of the locked nail is cut away and the tip of the nail is driven to the subchondral bone of the distal femur. The advantage of this technique is the minimal dissection for these difficult fractures. The splinting effect of the intramedullary nail decreases the incidence of refracture in the geriatric patient in whom refractures are relatively common. However, this technique may not be applicable in very distal fracture and condylar fracture which cannot be reduced by closed methods, and condylar fracture in the sagittal plane.     

Lateral traction apparatus for the upper extremity

Though ambulatory treatment of fractures of the upper extremity is usually the treatment of choice, bed treatment may be necessary and lateral traction required. Other conditions, such as burns, wounds, contractions and dislocations of the hand and arm may require elevation, splinting, or traction. No simple device for lateral traction is readily available in most hospitals and improvised methods may not prove altogether satisfactory. A lateral traction device designed by the author is herewith presented.